input
stringlengths 959
175k
| label
stringlengths 59
25k
|
|---|---|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Cipro / calcium channel blockers / amlodipine
Attending: ___.
Chief Complaint:
Left mid-shaft femur fracture
Major Surgical or Invasive Procedure:
___ Left femur open reduction and internal fixation with
trochanteric fixation nail system
History of Present Illness:
___ with hx of bilateral TKR pw left femur fracture s/p fall.
Patient was ambulating with walker and fell. Seen at OSH and
noted to have midshaft left femur fracture. Denies recent fevers
or chills. Denies numbness, tingling. Only endorsing pain at her
left femur.
Past Medical History:
Breast Cancer s/p surgery and radiation, currently on letrozole
HTN
CHF with EF of 49% per family
GERD
CAD no hx of MI or stenting
HL
Social History:
___
Family History:
Non-contributory
Physical Exam:
Admission Physical Examination
T99.7 HR58 BP116/59 RR16 O2 97% 2L
A&O x 3
Calm and comfortable
BLE skin clean and intact
Deformity of left thigh.
ttp at left midthigh
No edema, induration or ecchymosis
Thighs and leg compartments soft
Saphenous, Sural, Deep peroneal, Superficial peroneal SILT
___ ___ ___ TA Peroneals Fire
2+ ___ and DP pulses
Discharge Physical Examination
General: Awake, alert, no acute distress
Vitals: T = 98.3, HR = 78, BP = 112/60, RR = 18, O2Sat = 93% RA
Left lower extremity: incisions clean/dry/intact without
erythema or drainage, wwp, 2+ DP pulse, SILT s/s/sp/dp/tib, (+)
motor ___
Pertinent Results:
LABORATORY
On admisison
___ 11:37AM GLUCOSE-143* UREA N-24* CREAT-1.0 SODIUM-142
POTASSIUM-3.3 CHLORIDE-107 TOTAL CO2-24 ANION GAP-14
___ 11:37AM CALCIUM-7.9* PHOSPHATE-3.3 MAGNESIUM-1.4*
___ 01:15AM WBC-14.1* RBC-3.54* HGB-11.1* HCT-32.4*
MCV-91 MCH-31.3 MCHC-34.3 RDW-14.6
___ 01:15AM PLT COUNT-235
___ 01:15AM ___ PTT-24.2* ___
On discharge
___ 06:12AM BLOOD WBC-11.1* RBC-3.17*# Hgb-9.9*# Hct-29.0*
MCV-91 MCH-31.1 MCHC-34.0 RDW-15.6* Plt ___
___ 06:12AM BLOOD Plt ___
___ 06:12AM BLOOD Glucose-107* UreaN-19 Creat-1.0 Na-139
K-3.6 Cl-107 HCO3-28 AnGap-8
___ 06:12AM BLOOD Calcium-8.2* Phos-1.7* Mg-2.0
IMAGING
___ Plain Films Pelvis, Left femur: No fracture or
dislocation. No pubic symphysis or sacroiliac joint diastasis.
Degenerative changes are present of the sacroiliac joint and the
pubic symphysis. The alignment of a left femur midshaft fracture
has improved with an external fixation device. The distal
fragment remains displaced approximately 2 cm superiorly and 1.3
cm laterally. Left knee replacement is incompletely evaluated
PATHOLOGY
___ Left femur tissue reamings: pending at time of
discharge
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Omeprazole 20 mg PO DAILY
2. Lisinopril 40 mg PO DAILY
3. HydrALAzine 30 mg PO TID
4. Atacand HCT *NF* (candesartan-hydrochlorothiazid) 32-25 mg
Oral qday
5. Aspirin 81 mg PO DAILY
6. Centrum Silver *NF* (multivitamin-minerals-lutein;<br>mv with
min-lycopene-lutein;<br>mv-min-folic acid-lutein) 0.4-300-250
mg-mcg-mcg Oral qday
7. Citracal + D *NF* (calcium phosphate-vitamin D3) 250 mg
calcium- 250 unit Oral bid
8. Meclizine 25 mg PO Q8H:PRN vetigo
9. selenium *NF* 200 mcg Oral qday
10. Klor-Con M20 *NF* (potassium chloride) 20 mEq Oral qday
11. Fish Oil (Omega 3) 1000 mg PO DAILY
12. Simvastatin 20 mg PO DAILY
13. letrozole *NF* 2.5 mg Oral qday
Discharge Medications:
1. Fish Oil (Omega 3) 1000 mg PO DAILY
2. letrozole *NF* 2.5 mg Oral qday
3. Lisinopril 40 mg PO DAILY
4. Omeprazole 20 mg PO DAILY
5. Simvastatin 20 mg PO DAILY
6. Acetaminophen 650 mg PO Q6H
7. Docusate Sodium 100 mg PO BID
8. Enoxaparin Sodium 40 mg SC Q 24H Duration: 14 Days
9. Multivitamins 1 TAB PO DAILY
10. OxycoDONE (Immediate Release) 2.5-5.0 mg PO Q4H:PRN Pain
11. Senna 1 TAB PO DAILY
12. Aspirin 81 mg PO DAILY
13. Atacand HCT *NF* (candesartan-hydrochlorothiazid) 32-25 mg
Oral qday
14. Centrum Silver *NF* (multivitamin-minerals-lutein;<br>mv
with min-lycopene-lutein;<br>mv-min-folic acid-lutein)
0.4-300-250 mg-mcg-mcg Oral qday
15. Citracal + D *NF* (calcium phosphate-vitamin D3) 250 mg
calcium- 250 unit Oral bid
16. HydrALAzine 30 mg PO TID
17. Klor-Con M20 *NF* (potassium chloride) 20 mEq Oral qday
18. Meclizine 25 mg PO Q8H:PRN vetigo
19. Metoprolol Succinate XL 200 mg PO DAILY
20. selenium *NF* 200 mcg Oral qday
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Left femoral midshaft femur fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
HISTORY: ___ female with left femur fracture status post external
fixation.
COMPARISON: Reference radiographs of ___ at 17:24.
FINDINGS:
PELVIS, 1 VIEW: No fracture or dislocation. No pubic symphysis or sacroiliac
joint diastasis. Degenerative changes are present of the sacroiliac joint and
the pubic symphysis.
LEFT FEMUR, FRONTAL VIEWS: The alignment of a left femur midshaft fracture
has improved with an external fixation device. The distal fragment remains
displaced approximately 2 cm superiorly and 1.3 cm laterally. Left knee
replacement is incompletely evaluated.
IMPRESSION: Improved alignment of left femur midshaft fracture, with residual
superior and lateral displacement of the distal fragment.
Radiology Report
HISTORY: ORIF left femur.
Fluoroscopic assistance provided to surgeon in the OR without the radiologist
present. Six spot views obtained. Fluoro time recorded as 219.2 seconds on
the electronic requisition. Correlation with real-time findings and when
appropriate conventional radiographs is recommended for full assessment.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: LOWER EXTREMITY INJURY
Diagnosed with FX FEMUR SHAFT-CLOSED, UNSPECIFIED FALL
temperature: 99.7
heartrate: 58.0
resprate: 16.0
o2sat: 97.0
sbp: 116.0
dbp: 59.0
level of pain: 2
level of acuity: 3.0 | The patient was admitted to the orthopaedic surgery service on
___ with left midshaft femur fracture. Patient was taken
to the operating room and underwent open reduction and internal
fixation of left femur with trochanteric fixation nail. Patient
tolerated the procedure without difficulty and was transferred
to the PACU, then the floor in stable condition. Please see
operative report for full details.
Musculoskeletal: prior to operation, patient was non-weight
bearing left leg. After procedure, patient's weight-bearing
status was transitioned to weight-bearing as tolerated on left
leg. Throughout the hospitalization, patient worked with
physical therapy.
Neuro: post-operatively, patient's pain was controlled by
Dilaudid PCA and was subsequently transitioned to oxycodone with
good effect and adequate pain control.
CV: The patient was stable from a cardiovascular standpoint;
vital signs were routinely monitored.
Hematology: The patient was transfused 2 units of blood for
acute blood loss anemia. Hematocrit stabilized to 29.0 upon
discharge.
Pulmonary: The patient was stable from a pulmonary standpoint;
vital signs were routinely monitored.
GI/GU: A po diet was tolerated well. Patient was also started on
a bowel regimen to encourage bowel movement. Intake and output
were closely monitored.
ID: The patient received perioperative antibiotics. The
patient's temperature was closely watched for signs of
infection.
Prophylaxis: The patient received enoxaparin during this stay,
and was encouraged to get up and ambulate as early as possible.
At the time of discharge on ___, POD #3. the patient was
doing well, afebrile with stable vital signs, tolerating a
regular diet, ambulating, voiding without assistance, and pain
was well controlled. The incision was clean, dry, and intact
without evidence of erythema or drainage; the extremity was NVI
distally throughout. The patient was given written instructions
concerning precautionary instructions and the appropriate
follow-up care. The patient will be continued on chemical DVT
prophylaxis for 2 weeks post-operatively. All questions were
answered prior to discharge and the patient expressed readiness
for discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is an ___ ___ woman with PMH of CAD
(NSTEMI s/p stent left circumflex & RCA in ___, HTN, HLD, PVD
and asthma who presents with dyspnea. Pt reports that the
shortness of breath began during adult day-care today, around
12PM. It began suddenly, which she states is usually the case
for her asthma attacks. She was given O2 in the center and her
SOB improved. The SOB worsened when she was off the O2 on her
way home. Upon her arrival home, she appeared in distress to her
daughter, tachypneic, and she had a supported fall. Her SOB did
not improve with albuterol and so her daughter called an
ambulance. She reports very mild CP associated with this attack
today. She denies fevers, chills, palpitations, syncope, leg
swelling, orthopnea, or PND.
She began having episodic SOB and was diagnosed with asthma
about ___ years ago. She has been having daily SOB asthma attacks
which usually improve with albuterol. However, possibly due to
incorrect use of her inhaler, she is usually out of her
albuterol before she can get another one. On a few occasions,
she had to use her daughter's inhaler to control her attacks.
She is not recieving any other treatment for her asthma at the
moment. Today's attack seemed the most severe in these ___ years.
In the ED, initial vital signs were 98.4 67 147/67 24 100% 10L
Non-Rebreather. She initially required a non-rebreather. Chem-7
and CBC with eosinophilia. Trop-T: <0.01, BNP EKG showed NSR @
54, LVH, lateral st depressions (old) no STE or new ischemic
changes. CXR was negative for pulmonary edema or infiltrate.
Patient was given duonebs x4, magnesium 2g, and
methylprednisolone 125mg. Pt improved with treatment but still
very tight on exam.
On transfer Vitals were BP 109/55 HR 58, RR 14, 99% O2 on 6L
Neb. She feels much better, and reports no SOB or CP.
Review of Systems:
(+) per HPI+ dysuria, burning on urination, frequent urination.
(-) fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, chest pain,
abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR,
melena, hematochezia, hematuria.
Past Medical History:
- Asthma (diagnosed ___ years ago at age ___
- CAD, status post inferior NSTEMI with stent placement in L
circumflex and RCA in ___ myocardial perfusion scan(___)
- Medium size infarct involving the inferolateral wall w/
minimal ___ ischemia.Severe inferolateral hypokinesis.
(EF: 64%. Cath ___: Patent PRCA stent, 40% mid vessel stenosis.
Echo ___: Mild regional LV dysfunction with inferior lateral
hypokinesis, EF 50%, ___ AR, ___
- Hypertension
- Peripheral vascular disease
- Adjustment with depressed mood
- s/p right eye cataract surgery (R eye ___ at ___)
- s/p L eye cataract surgery ___
Social History:
___
Family History:
Asthma in brother, daughter and grandaughter.
Mother died in childbirth.
No other known.
Physical Exam:
ADMISSION:
VS: T 98.5, BP 140/68, HR 67, RR 20, ___,
GENERAL: thin woman uncomfortable, somewhat tearful
HEENT: NC/AT PERRL EOMI, sclera anicteric, MMM OP clear
NECK: supple, no LAD, no JVD, no thyromegaly
CARDIAC: distant sounds. RRR, S1, S2, no m/r/g
CHEST: somewhat scoliotic
LUNG: some wheezing bilaterally. distant lung sounds
ABDOMEN: soft NT ND +BS no organomegally
GU: no foley
EXT: Severe arthritic changes in hands, ulnar deviation. WWP no
c/c/e 2+ radial DP, ___, strength ___ BUE and BLE.
Neuro: aaox3
Skin: no rashes, excoriations
Discharge:
Vitals: 98 (111-162/51-68) 67 20 98%/3L
General: thin frail elderly female, lying in bed in NAD
HEENT: NCAT, PERRL, EOMI, MMM, OP clear
Neck: no LAD, no JVD
CV: distant heart sounds S1,S2 no murmurs
Lungs: increased respiratory effort, poor air movement b/l, no
whezzing
Abdomen: firm, NT ND, +BS no hepatomegaly
GU: no foley
Ext: cool, 1+DP, moving all 4 extremities
Neuro: AAOx3, CN grossly intact no focal neurologic deficits
Skin: no rashes
Pertinent Results:
___ 04:19PM BLOOD WBC-6.5 RBC-4.24 Hgb-13.2 Hct-38.0 MCV-90
MCH-31.1 MCHC-34.7 RDW-12.7 Plt ___
___ 04:19PM BLOOD Neuts-73.5* Lymphs-14.9* Monos-5.1
Eos-5.8* Baso-0.7
___ 04:19PM BLOOD ___ PTT-34.5 ___
___ 04:19PM BLOOD Plt ___
___ 04:19PM BLOOD Glucose-134* UreaN-18 Creat-1.0 Na-133
K-4.4 Cl-99 HCO3-24 AnGap-14
___ 04:19PM BLOOD cTropnT-<0.01
___ 04:19PM BLOOD Calcium-8.9 Phos-4.0 Mg-2.0
___ 04:31PM BLOOD Type-ART Temp-36.9 pO2-126* pCO2-44
pH-7.38 calTCO2-27 Base XS-0 Intubat-NOT INTUBA Comment-O2
DELIVER
___ 04:31PM BLOOD Lactate-1.1
___ 04:31PM BLOOD O2 Sat-98
URINE:
___ 06:41PM URINE Color-Straw Appear-Clear Sp ___
___ 06:41PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
___ 06:41PM URINE RBC-<1 WBC-1 Bacteri-NONE Yeast-NONE
Epi-0
___ 06:41PM URINE CastHy-1*
___ 06:41PM URINE Mucous-RARE
MICRO:
___ URINE URINE CULTURE-PENDING
___ BLOOD CULTURE Blood Culture, Routine-PENDING
___ BLOOD CULTURE Blood Culture, Routine-PENDING
Imaging:
CXR (___): Possible bilateral pleural effusions with small
retrocardiac opacity consistent with atelectasis or
consolidation.
Discharge: None
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Calcium Carbonate 600 mg PO BID
2. Docusate Sodium 100 mg PO BID
3. Albuterol-Ipratropium 2 PUFF IH Q6H
4. Fluticasone Propionate 110mcg 2 PUFF IH BID
5. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
hold for sbp<100
6. Atorvastatin 80 mg PO DAILY
7. Nitroglycerin SL 0.3 mg SL PRN chest pain
8. Clopidogrel 75 mg PO DAILY
9. Acetaminophen 1000 mg PO Q8H:PRN pain
10. Aspirin 81 mg PO DAILY
11. Atenolol 50 mg PO DAILY
12. Losartan Potassium 100 mg PO DAILY
hold for SBP<100
13. Mirtazapine 15 mg PO HS
14. Polyethylene Glycol 17 g PO DAILY:PRN constipation
15. Senna 1 TAB PO DAILY
16. Vitamin D 400 UNIT PO BID
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN pain
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO DAILY
4. Calcium Carbonate 600 mg PO BID
5. Clopidogrel 75 mg PO DAILY
6. Docusate Sodium 100 mg PO BID
7. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
8. Losartan Potassium 100 mg PO DAILY
9. Mirtazapine 15 mg PO HS
10. Polyethylene Glycol 17 g PO DAILY:PRN constipation
11. Senna 1 TAB PO DAILY
12. Vitamin D 400 UNIT PO BID
13. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN wheezing SOB
RX *albuterol sulfate 2.5 mg/3 mL (0.083 %) 2.5 mg NEB Q4H:PRN
Disp #*60 Vial Refills:*0
14. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
RX *fluticasone-salmeterol [Advair Diskus] 250 mcg-50 mcg/Dose 1
IH INH twice a day Disp #*1 Inhaler Refills:*0
15. Metoprolol Succinate XL 50 mg PO DAILY
hold for HR<60 or BP<100
RX *metoprolol succinate 50 mg 1 tablet extended release 24
hr(s) by mouth Daily Disp #*30 Tablet Refills:*0
16. PredniSONE 40 mg PO DAILY Duration: 9 Days
RX *prednisone 20 mg 2 tablet(s) by mouth Daily Disp #*18 Tablet
Refills:*0
17. Tiotropium Bromide 1 CAP IH DAILY
RX *tiotropium bromide [Spiriva with HandiHaler] 18 mcg 1 CAP IH
Daily Disp #*30 Capsule Refills:*0
18. Nitroglycerin SL 0.3 mg SL PRN chest pain
19. Albuterol Inhaler 2 PUFF IH Q4H:PRN asthma
Please use either the albuterol inhaler or nebulizer and not
together at the same time.
RX *albuterol sulfate 90 mcg 2 PUFF IH every four (4) hours Disp
#*1 Inhaler Refills:*0
20. Nebulizer machine
Diagnosis: Reactive Airway Disease
Needed for albuterol treatments
21. Inhaler spacer
Please provide an inhaler spacer for albuterol inhaler.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
Hypoxia secondary to reactive airway disease
Secondary:
CAD
HTN
HLD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: ___ female with shortness of breath.
COMPARISON: Multiple prior exams, most recently of ___.
FINDINGS:
Single frontal view of the chest. The heart size is mildly enlarged and
cardiomediastinal contours are stable. The bilateral costophrenic angles are
indistinct, potentially due to effusions or potentially in part due to
overlying soft tissues and technique. Retrocardiac opacity could represent
atelectasis or consolidation. No pneumothorax.
IMPRESSION:
Possible bilateral pleural effusions with small retrocardiac opacity
consistent with atelectasis or consolidation.
Gender: F
Race: BLACK/CAPE VERDEAN
Arrive by WALK IN
Chief complaint: DYSPNEA
Diagnosed with ASTHMA, UNSPECIFIED, WITH ACUTE EXACERBATION
temperature: 98.4
heartrate: 67.0
resprate: 24.0
o2sat: 100.0
sbp: 147.0
dbp: 67.0
level of pain: 0
level of acuity: 2.0 | Ms. ___ is an ___ ___ woman with PMH of CAD
(NSTEMI with stent placement to left circumflex & RCA in ___,
and asthma who presents with dyspnea from likely asthma
exacerbation/reactive airway disease.
# SOB: Pt with severe dyspnea on admission with hypoxia
requiring non-rebreather. Patient takes
combivent(albuterol/ipratropium) and fluticasone as an
outpatient consistent with reactive airway disease. Concurrent
COPD is also a possibility with pt's smoking hx and increased
severity of SOB. She was treated with steroids and
albuterol/ipratropium nebulizers and her symptoms improved and
she was able to be weaned to room air. On discharge her
Ambulatory O2 sat was 93%RA and resting O2 sat 95%RA. She was
discharged on prednisone 40mg for total 10 days, Advair,
albuterol, and Spiriva. She was also provided with a nebulizer
for albuterol. Should consider PFTs as an outpatient once
current exacerbation resolves to determine underlying
physiology. She was discharged with a nebulizer for albuterol
treatments as well.
# CAD: Pt with prior NSTEMI with stent placement to left
circumflex & RCA in ___. No current symptoms. We continued
aspirin 81 mg daily and Plavix 75 mg tablet Daily. We switched
atenolol 50 mg daily to metoprolol succinate 50mg daily.
# HTN: BP stable. We Continued Imdur 30 mg Daily, losartan 100
mg daily, and
metoprolol succinate 50 mg daily.
# HLD: We continued Lipitor 80 mg Daily. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Opioids - Morphine Analogues / propoxyphene
Attending: ___.
Chief Complaint:
falls and ___ weakness
Major Surgical or Invasive Procedure:
CERVICAL DECOMPRESSION AND FUSION C4-C7
History of Present Illness:
___ hx of MR presents from ___ s/p fall. She lives
alone and had a mechanical fall hitting her right orbit and
right knee. She was transferred here for neurology evaluation
for multiple falls over the last month for which she has been
doing ___. She states that for about 1 month she has had problems
with balance and multiple falls. She denies any new neck pain,
back pain, weakness, numbness, urinary or bowel incontinence,
saddle anesthesia or fever. Her friends have ___ been
concerned about left sided weakness and intermittent dysarthria.
The spine service was consulted for a c5-c6 osteophyte seen on
CT c-spine reportedly causing spinal stenosis. IMAGING:CT
c-spine c5-6 osteophyte with central canal stenosis
Past Medical History:
Developmental delay
Osteoporosis
HLD
GERD
PPM
remote hx of seizures but off meds
Social History:
no smoking or IVDU, lives in assisted living
Physical Exam:
Orthopaedic Spine Consult Physical Exam ___-
In general, the patient is in no acute distress.
Vitals: 97.8 86 150/74 16 98% RA
a&ox3
abrasion right orbit
RRR
no increased WOB
soft, NT/ND
bilateral upper extremity tremor
Spine exam: no C, T, L or S tenderness
Vascular
Radial: L2+, R2+
DPR: L2+, R2+
Motor-
Delt Bic Tri WrE FFl FE IO IP glut Quad Ham TA Gastroc
L 5 ___ ___ 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5
No muscle wasting.
-Sensory:
Sensory UE
C5 (Ax) R nl, L nl
C6 (MC) R nl, L nl
C7 (Mid finger) R nl, L nl
C8 (MACN) R nl, L nl
T1 (MBCN) R nl, L nl
T2-L2 Trunk R nl, L nl
Sensory ___
L2 (Groin): R nl, L nl
L3 (Leg) R nl, L nl
L4 (Knee) R nl, L nl
L5 (Grt Toe): R nl, L nl
S1 (Sm toe): R nl, L nl
S2 (Post Thigh): R nl, L nl
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 2
R 2 2 2 2 2
___: neg
Babinski: upgoing bilaterally
Clonus: none
Perianal sensation: intact
Rectal tone: intact
BUE skin clean and intact
No tenderness, deformity, erythema, edema, induration or
ecchymosis
Arms and forearm compartments soft
No pain with passive motion
Axillary, Radial, Median, Ulnar SILT
EPL FPL EIP EDC FDP FDS fire
Pelvis stable to AP and lateral compression.
BLE skin clean, R knee abrasion
No tenderness, deformity, erythema, edema, induration or
ecchymosis
Thighs and leg compartments soft
No pain with passive motion
Saphenous, Sural, Deep peroneal, Superficial peroneal SILT
___ ___ TA Peroneals Fire
Pertinent Results:
___ 12:50PM BLOOD WBC-8.6 RBC-3.96* Hgb-10.9* Hct-34.3*
MCV-87 MCH-27.6 MCHC-31.8 RDW-14.9 Plt ___
___ 08:48AM BLOOD Neuts-73.1* ___ Monos-4.8 Eos-1.4
Baso-0.3
___ 12:50PM BLOOD Plt ___
___ 12:50PM BLOOD Glucose-96 UreaN-11 Creat-0.7 Na-141
K-4.0 Cl-105 HCO3-27 AnGap-13
___ 01:50AM BLOOD Calcium-7.9* Phos-2.7 Mg-1.8
___
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ year old woman with developmental delay status
post C3-7
decompression fusion now altered mental status and possibly
aphasia and
decreased right-sided movement. Please evaluate for bleed or
intracranial
process.
TECHNIQUE: Contiguous axial images of the brain were obtained
without
contrast. Coronal and sagittal as well as thin bone-algorithm
reconstructed images were obtained.
DOSE: DLP: 1212 mGy-cm
CTDI: 54 mGy
COMPARISON: CT from ___.
FINDINGS:
Evaluation is limited secondary to patient motion. There is no
evidence of acute hemorrhage, mass effect, edema or infarctions.
The ventricles and sulci are stable in size and configuration.
Cavum septum pellucidum et vergae is incidentally noted.
No osseous abnormalities seen. There is left maxillary and
bilateral ethmoid air cell mucosal thickening. The other
paranasal sinuses, mastoid air cells and middle ear cavities are
clear. The orbits are unremarkable.
IMPRESSION:
Evaluation is limited secondary to patient motion. No definite
evidence of acute intracranial process.
___
EXAMINATION: CT C-SPINE W/O CONTRAST
INDICATION: ___ year old woman with developmental delay status
post C3-7
decompression and fusion now with altered mental status and
aphasia and
decreased right sided movement. Please evaluate for cervical
spine hematoma post-operatively.
TECHNIQUE: Contiguous axial images were obtained of the
cervical spine.
Sagittal and coronal reformatted images were generated. No
contrast was
administered.
CTDIvol: 669 mGy
DLP: 32 mGy-cm
COMPARISON: CT from ___.
FINDINGS:
Evaluation is limited secondary to patient motion. The patient
is status post laminectomy and posterior fusion spanning from
C3-C7. The surgical drain is seen along posterior aspect of the
spinal canal, entering at C6, with the tip terminating at the
level of C4 on the right. There are multilevel degenerative
changes as noted before with endplate irregularity, disc height
loss and posterior osteophytosis most notable at C5-C6.
Evaluation of the central canal is limited due to technique and
patient motion, though no definitive hematoma is seen.
IMPRESSION:
1. Evaluation is limited secondary to motion. Status post
laminectomy and
posterior fusion spanning from C3-C7, with a surgical drain at
the level of C6, with the tip terminating at the level of C4 and
right.
2. The central canal is not well evaluated on CT and motion
artifact limits evaluation, though no large hematoma is seen.
Medications on Admission:
Citalopram
Fludrocortisone
Pantoprazole
Simvastatin
Tramadol
Discharge Medications:
1. Acetaminophen 650 mg PO TID
2. Citalopram 10 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Fludrocortisone Acetate 0.1 mg PO DAILY
5. Pantoprazole 40 mg PO Q24H
6. Senna 17.2 mg PO HS
7. Simvastatin 40 mg PO QPM
8. TraMADOL (Ultram) 25 mg PO Q6H:PRN pain
9. TraZODone 25 mg PO HS:PRN insomnia
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
C5-6 osteophyte
central stenosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CTA HEAD AND CTA NECK
INDICATION: ___ year old woman s/p C4-6Decompression/C3-7 Fusion on ___
here with imaging concerning for stroke. R/o vascular stenosis.
TECHNIQUE: Contiguous axial images were obtained through the brain without
contrast material. Subsequently, rapid axial imaging was performed from the
aortic arch through the brain during infusion of Omnipaque intravenous
contrast material. Three-dimensional angiographic volume rendered, curved
reformatted and segmented images were generated. This report is based on
interpretation of all of these images.
DOSE: DLP: 2628.43 mGy-cm; CTDI: 55.75 mGy
COMPARISON: CT head from ___.
FINDINGS:
Streak artifact from the recent C3-7 spinal fusion hardware degrades image
quality and limits evaluation.
Head CT: There is no evidence of hemorrhage, edema, masses, mass effect, or
infarction. The ventricles and sulci are normal in caliber with anatomical
variation consistent with septum cavum pellucidum et vergae. No fractures are
identified. There is a grossly unchanged air-fluid level in the left
maxillary sinus, suggesting a chronic inflammatory process.
Incidental note of right lung apical scarring is made (3:68), warranting
clinical correlation with dedicated chest imaging if necessary. Patient is
status post C3-C7 posterior spinal fusion, with no perihardware lucency to
suggest loosening. Degenerative changes of the cervical spine are again noted.
Periodontal disease/ periapical lucency of the left incisor is noted.
Head CTA: There are no intracranial vascular abnormalities. There is no
evidence of aneurysm, stenosis or occlusion. Atherosclerotic calcifications of
the cavernous portions of the bilateral internal carotid arteries are
identified.
Neck CTA: The carotid and vertebral arteries and their major branches are
patent with no evidence of stenoses. The right carotid artery measures 5.9 mm
proximally and 4.0 mm distally. The left carotid artery measures 7.5 mm
proximally and 4.4 mm distally. There is no evidence of internal carotid
stenosis by NASCET criteria.
IMPRESSION:
1. No evidence of vascular stenosis.
2. Status post C3-C7 posterior spinal fusion. Streak artifact from the
hardware degrades image quality and limits evaluation.
3. Incidental note of right lung apical scarring is made, warranting clinical
correlation and dedicated chest imaging, if clinically indicated.
Radiology Report
EXAMINATION: CERVICAL SINGLE VIEW IN OR
INDICATION: C4-C7 fusion.
TECHNIQUE: Screening provided operating room without a radiologist present.
FINDINGS:
Images demonstrate instrumentation of the cervical spine and posterior fusion.
Fused levels appear to be C3 through C7. For details of the procedure, please
consult the procedure report.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ year old woman with developmental delay status post C3-7
decompression fusion now altered mental status and possibly aphasia and
decreased right-sided movement. Please evaluate for bleed or intracranial
process.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal as well as thin bone-algorithm reconstructed
images were obtained.
DOSE: DLP: 1212 mGy-cm
CTDI: 54 mGy
COMPARISON: CT from ___.
FINDINGS:
Evaluation is limited secondary to patient motion. There is no evidence of
acute hemorrhage, mass effect, edema or infarctions. The ventricles and sulci
are stable in size and configuration. Cavum septum pellucidum et vergae is
incidentally noted.
No osseous abnormalities seen. There is left maxillary and bilateral ethmoid
air cell mucosal thickening. The other paranasal sinuses, mastoid air cells
and middle ear cavities are clear. The orbits are unremarkable.
IMPRESSION:
Evaluation is limited secondary to patient motion. No definite evidence of
acute intracranial process.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST
INDICATION: ___ year old woman with developmental delay status post C3-7
decompression and fusion now with altered mental status and aphasia and
decreased right sided movement. Please evaluate for cervical spine hematoma
post-operatively.
TECHNIQUE: Contiguous axial images were obtained of the cervical spine.
Sagittal and coronal reformatted images were generated. No contrast was
administered.
CTDIvol: 669 mGy
DLP: 32 mGy-cm
COMPARISON: CT from ___.
FINDINGS:
Evaluation is limited secondary to patient motion. The patient is status post
laminectomy and posterior fusion spanning from C3-C7. The surgical drain is
seen along posterior aspect of the spinal canal, entering at C6, with the tip
terminating at the level of C4 on the right. There are multilevel degenerative
changes as noted before with endplate irregularity, disc height loss and
posterior osteophytosis most notable at C5-C6. Evaluation of the central canal
is limited due to technique and patient motion, though no definitive hematoma
is seen.
IMPRESSION:
1. Evaluation is limited secondary to motion. Status post laminectomy and
posterior fusion spanning from C3-C7, with a surgical drain at the level of
C6, with the tip terminating at the level of C4 and right.
2. The central canal is not well evaluated on CT and motion artifact limits
evaluation, though no large hematoma is seen.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: s/p Fall, Transfer
Diagnosed with ABNORMALITY OF GAIT, UNSPECIFIED FALL
temperature: 97.8
heartrate: 86.0
resprate: 16.0
o2sat: 98.0
sbp: 150.0
dbp: 74.0
level of pain: 4
level of acuity: 3.0 | ___ was transferred here for neurology evaluation for multiple
falls over the last month. CT c-spine shows c5-6 osteophyte with
central canal stenosis. The patient was admitted to the ___
Spine Surgery Service and taken to the Operating Room for the
above procedure. Refer to the dictated operative note for
further details. The surgery was without complication and the
patient was transferred to the PACU in a stable condition.
TEDs/pnemoboots were used for postoperative DVT prophylaxis.
Intravenous antibiotics were continued for 24hrs postop per
standard protocol. Initial postop pain was controlled with PO
and IV for breakthrough pain. Diet was advanced as tolerated.
Foley remains for UOP monitoring and will need to be dc'd when
patient is more ambulatory. Physical therapy was consulted for
mobilization OOB to ambulate. Postop course was complicated by
complex partial seizure with resultant Tod's paralysis in the
setting of surgery and sleep deprivation per neurology with
quick return to baseline. No anti epileptics indicated at this
time per neurology. In the initial neurology w/u, a CT scan on
___ was questionable for hypodensity concerning for stroke.
A Repeat CT scan was done on ___ also concerning for
hypodensity. The imaging was reviewed with Dr. ___ with
___ and was felt that the hypodensities were artifact and
does not need further neurological work-up. It was felt that her
myelopathy was due to her central stenosis and was treated
surgically. She has not had any further siezures, episodes of
slurred speech or increased weakness post-op. She had a repeat
physical therapy evaluation for which Rehab is recommended.
Hospital course was otherwise unremarkable. On the day of
discharge the patient was afebrile with stable vital signs,
comfortable on oral pain control and tolerating a regular diet. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Percocet / Codeine / Darvocet-N 100 / Demerol / Maxalt / Vimpat
/ acetaminophen
Attending: ___.
Chief Complaint:
Left thigh pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ with history of anxiety, heroin abuse on
methadone, reported seizure disorder, fibromyalgia and other
comorbidities who presents with one month of posterior left
thigh pain and swelling.
It appears she initially presented to the ED, left AMA with Rx
for oral antibiotics and then represented. Upon the second
presentation, she agreed to bedside I&D, which was
uncomplicated.
She reported to the ED that she has had increasing pain,
swelling of the posterior left thigh over the past month after
she sustained a cut driving her boyfriend's car. At this point
it had progressed to the point she had difficulty walking. She
had similar abscesses on the right leg in the past that required
incision and drainage under anesthesia. She reported relapsing
on heroin 3 times in past two days to self-medicate her leg
pain. Last use day prior to ED evaluation. Both times she
overdosed and her boyfriend gave her narcan. Reports SI in the
ED, but no plan. She reported she had a
suicide attempt one month ago but did not elaborate. She was
evaluated by psychiatry during one of her ED presentations, and
was deemed to have capacity and able to leave AMA. Please see
psychiatry note from ___.
I
n the ED, initial vitals were: ___ pain, temp 97 (remained
afebrile), BP 131/65, RR 14, 100% on RA.
Labs notable for:
Imaging notable for:
WBC 11.3 with normal differential. CRP 38.7. Normal BMP. Serum
tox screen negative. Urine tox screen positive for benzos,
opriates, cocaine, methadone.
Patient was given:
clonazepam 1mg, morphine 4mg IV, lorazepam 2mg, clonidine 0.1mg,
morphine sulfate 2mg IV, and amp-sulbactam 3mg IV and underwent
bedside I&D of the left lateral thigh.
Vitals prior to transfer: 98.2, 91, 93/49, 16, 97% on RA
On the floor, she was sleeping, oversedated and arouse to light
physical contact and loud voice. She endorsed feeling "like
crap" but could not be more specific. She denied headache, chest
pain, abdominal pain, diarrhea. Was unable to give a reliable
complete ROS.
ROS:
(+) Per HPI
Limited by oversedation, see above.
Past Medical History:
- IVDU on methadone with recent relapse
- seizure condition (since childhood)
- history of abdominal pain, unclear etiology, resolved
- choledocholithiasis
- fibromyalgia
- restless leg syndrome
Social History:
___
Family History:
Unable to obtain
Physical Exam:
ADMISSION PHYSICAL EXAM
Vital Signs:
97.9, 107/68, 80, 18, 97% on RA
General: Sleeping, snoring, no acute distress. Difficult to
arouse. awakens to touch and voice. 3 word answers. Falls asleep
after each sentence. No apneic events.
HEENT: Sclera anicteric, pupils 4-5mm and reactive. MMM
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. Left lateral thigh with dressing from I&D C/D/I.
Neuro: face symemetric. Moves all extremities.
DISCHARGE PHYSICAL EXAM
Vital Signs: Tm 98 Tc 98 BP 102-137/55-79 HR ___ RR 18 O2Sat
96RA
General: Easily arousable, NAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
BACK: Tenderness to palpation of spinous processes and
paraspinal muscles of lower back
Abdomen: Soft, non-tender, non-distended, NABS, no rebound or
guarding
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. L lateral thigh w/gauze (not blood stained)
Pertinent Results:
ADMISSION LABS
------------------
___ 02:20PM BLOOD WBC-11.3* RBC-4.30 Hgb-12.7 Hct-39.7
MCV-92 MCH-29.5 MCHC-32.0 RDW-13.4 RDWSD-45.1 Plt ___
___ 02:20PM BLOOD Neuts-55.8 ___ Monos-5.3 Eos-2.4
Baso-0.3 Im ___ AbsNeut-6.32* AbsLymp-4.05* AbsMono-0.60
AbsEos-0.27 AbsBaso-0.03
___ 02:20PM BLOOD Glucose-89 UreaN-7 Creat-0.9 Na-137 K-5.1
Cl-101 HCO3-25 AnGap-16
___ 11:16AM BLOOD Calcium-9.1 Phos-2.4* Mg-2.0
___ 02:20PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
IMAGING
---------
CT LEFT LOWER EXTREMITY (___): 0.7 x 2.4 by 1.9 cm
subcutaneous collection in the left upper lateral thigh with
internal hyperdense material and gas locules. Evaluation for
abscess is limited given the lack of intravenous contrast. No
evidence of extension into the fascia or muscles of the thigh.
DISCHARGE/INTERVAL LABS
___ 10:40AM BLOOD WBC-10.4* RBC-3.88* Hgb-11.5 Hct-36.0
MCV-93 MCH-29.6 MCHC-31.9* RDW-13.9 RDWSD-46.7* Plt ___
___ 10:40AM BLOOD Glucose-85 UreaN-4* Creat-0.8 Na-141
K-4.0 Cl-103 HCO3-29 AnGap-13
___ 10:40AM BLOOD Calcium-8.9 Phos-2.9 Mg-2.1
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
2. ClonazePAM 1 mg PO TID
3. CloNIDine 0.3 mg PO QID
4. Gabapentin 400 mg PO QID
5. Ibuprofen 800 mg PO Q8H
6. LamoTRIgine 100 mg PO DAILY
7. Pregabalin 450 mg PO QAM
8. Pregabalin 300 mg PO QPM
9. Prazosin 2 mg PO QHS
10. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
DAILY
11. Promethazine 50 mg PO QAM
12. Promethazine 50 mg PO QPM
13. Pramipexole 0.5 mg PO QHS
Discharge Medications:
1. CloNIDine 0.3 mg PO TID
2. ClonazePAM 1 mg PO TID
3. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
4. Gabapentin 400 mg PO QID
5. Ibuprofen 800 mg PO Q8H
6. LamoTRIgine 100 mg PO DAILY
7. Pramipexole 0.5 mg PO QHS
8. Prazosin 2 mg PO QHS
9. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
DAILY
10. Promethazine 50 mg PO QAM
11. Promethazine 50 mg PO QPM
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Left lateral thigh abscess
Secondary: IVDU on methadone, seizure condition (since
childhood), abdominal pain of unclear etiology,
choledocholithiasis, fibromyalgia, restless leg syndrome
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ year old woman with L lateral and posterior thigh abscess s/p
incision and drainage on ___ // infection?
TECHNIQUE:
Axial images of the left lower extremity from the pelvis through the distal
femur were obtained without intravenous contrast. Sagittal and coronal
reformats were obtained and reviewed.
DOSE: Total exam DLP T: 1056.82
CTDIvol: 19.71
COMPARISON: None available
FINDINGS:
There is a 2.7 x 2.4 x 1.9 cm subcutaneous collection demonstrating internal
gas locules and hyperdense material and communicates with the skin (series 3,
image 27). There is associated skin thickening and subcutaneous fat
stranding. Evaluation for an abscess is limited in the lack of intravenous
contrast. The subcutaneous inflammatory changes do not extend to the muscular
fascia. No abnormal muscle enhancement or muscular edema.
IMPRESSION:
0.7 x 2.4 by 1.9 cm subcutaneous collection in the left upper lateral thigh
with internal hyperdense material and gas locules. Evaluation for abscess is
limited given the lack of intravenous contrast.
No evidence of extension into the fascia or muscles of the thigh.
Gender: F
Race: WHITE
Arrive by WALK IN
WALK IN
Chief complaint: L Leg swelling, L Leg pain
Wound eval
Diagnosed with Cellulitis of left lower limb
Cellulitis of left lower limb, Suicidal ideations
temperature: 97.0
98.5
heartrate: 76.0
63.0
resprate: 14.0
18.0
o2sat: 100.0
100.0
sbp: 131.0
120.0
dbp: 65.0
78.0
level of pain: 9
9
level of acuity: 3.0
3.0 | Ms. ___ is a ___ with a history of anxiety, heroin abuse on
methadone, reported seizure disorder, fibromyalgia and other
comorbidities who presents following one month of posterior left
thigh pain and swelling associated with an abscess, s/p I&D on
___ in the ED.
# Left lateral thigh abscess: Patient initially presented with a
leukocytosis (neutrophilic predominance) following incision and
drainage of the abscess. She remained entirely afebrile, but
endorsed pain at the incision site that improved throughout her
stay. As she was not demonstrating evidence of cellulitis around
her incision site, Unasyn was discontinued. CT of the left
lateral thigh did not demonstrate extension of the fluid into
the fascia or muscles of the thigh. Her leukoctyosis resolved.
Blood cultures are final negative.
# IVDU: Patient endorses 2 recent overdoses with heroin prior to
ED presentation, for which she was rescued with Narcan by her
boyfriend. She is currently on a Methadone blind taper and
receiving Methadone 52 mg daily through ___ from Habit ___
clinic. She experienced withdrawal symptoms (ie nausea,
vomiting, muscle aches, diarrhea, and chills) which were treated
symptomatically per ___ protocol. She will be discharged with a
prescription for Narcan and should follow-up with Habit ___
clinic after discharge. Social services worked with the patient
to establish a safe discharge plan.
# Seizure disorder: Unknown seizure disorder from childhood for
which she was continued on her home regimen of Gabapentin and
Lamictal (she denies taking Depakote for which she was
prescribed).
# Suicidal Ideations: Reportedly without plan or current intent
in the ED and was seen by psychiatry in the ED prior to sedation
and was not felt to have acute psychiatric needs. She requested
to speak to Social Work regarding this matter and materials for
addiction counseling as well as placement in more conducive
residential facilities were made.
TRANSITIONAL ISSUES
- Discuss Lyrica dose with her psychiatrist, Dr. ___, as
there is concern for oversedation with regards to the patient's
medication regimen
- Follow-up on pending blood cultures
- Follow up on quantiferon-TB gold
- Change the incision dressing every 2 days.
- Follow-up with ___ clinic (Habit OPCO) after discharge
to continue your Methadone taper.
- CODE: Full |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Dyspnea, "fluid in lungs"
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a ___ year old homeless man currently residing in
a
shelter with PMH of schizophrenia, heart failure with reduced
ejection fraction (EF 30%), CAD s/p CABG ___ with post-op
course complicated by persistent inotrope dependence and new
onset atrial fibrillation treated with amiodarone not on
anticoagulation.
The history is difficult to obtain as he refused to answer some
questions, however he reports several months of ongoing dyspnea
on exertion and "fluid in my lungs." He also reports
palpitations
during this time that make it unable for him to sleep. He denies
frank chest discomfort. He has never lost consciousness. He
sometimes has fluid in his legs, but he feels this is less
prominent now. He reports catching a "bug" in his shelter that
everyone had. He endorsed coughing up discolored sputum.
In the ED initial vitals were: 98.7 81 117/83 36 92% Nasal
Cannula
EKG showed NSR with TWI in V1 and no ST changes. Troponins were
<0.01 x2. BNP was 13304. WBC count was 12.9. CXR showed
cardiomegaly, moderate pulmonary edema, moderate right and
small left pleural effusions, and dense right basilar
opacity may represent atelectasis or pneumonia. He was
given
Lasix 80mg IV.
On the floor the patient continues to feel SOB and is worried
about his palpitations.
REVIEW OF SYSTEMS:
Positive per HPI. Otherwise ROS negative.
Past Medical History:
Past Psychiatric History: Per Dr. ___ note ___
(per chart review):
-Diagnoses: schizophrenia vs schizoaffective
-Hospitalizations: At least 5 prior psychiatric
hospitalizations, and a hospitalization "at ___ from ___
until ___
-Current treaters and treatment: No current treaters, last
treater Dr. ___ known to ___ Healthcare for the
homeless street team - ___ ___
-Medication and ECT trials: previously did well on Depakote
500mg BID and Abilify 15mg; also took zyprexa in the past
-Self-injury: "previous SI with plan to jump off bridge in
___
-Harm to others: History of assault
-Access to weapons: Unknown
-Arrests: ___ seen at ___, pt in police custody, thought to
be at potential harm towards others. Per ___ records h/o A&B
charges
-Convictions and jail terms: Unknown
-Guardian: ___: ___
PMH:
- ?PVD
- ___ Bilateral IPH, Bilateral ___ S/P AUTO-PED
- CAD
- STEMI ___
- CHF (30%)
Social History:
Substance use history:
-Alcohol: Extensive history with tendency toward violence when
intoxicated (quantities unknown)
-Tobacco: Unknown, but patient has in the hospital required
nicotine patches
-Illicits: Unknown
.
Personal and Social History: Collateral from ___
___ for the Homeless, street outreach team
(___) (Per Dr. ___ note ___: ___
knows Mr. ___ well and was actually looking for him today.
Patient was supposed to be evicted today due to hoarding
behaviors and ___ was able to obtain a shelter bed for him at
___. He had JRI support in his unit but it was not
sufficient. He has a history of schizophrenia vs schizoaffective
but she definitely thinks there's a mood component to his mental
illness. He is often grandiose and delusional. He has been off
meds for years and currently does not have a psychiatric
provider. His last psychiatrist was Dr. ___ at ___
___. Of note, Mr. ___ has been complaining of abdominal
pain for some months but has not follow-up due to delusional
thinking. ___ anticipates that Mr. ___ will be agitated
upon extubation given his level of paranoia. She says she is
available to come
see him (on weekdays) if that would be helpful.
Family History:
Unknown; Patient does not recall family history.
Physical Exam:
ADMISSION PHYSICAL EXAM
VS: 97.5 95 / 62 87 22 94 3L
Weight: refused
General: disheveled, malodorous, shouting
CV: refused JVP examination, tachycardic, regular rhythm, no
murmurs
PULM: crackles to mid lung fields, increased work of breathing,
no wheezes
ABD: soft, NT, ND
EXT: trace ___ edema R>L, wwp, chronic venous stasis changes
PSYCH: pressured speech, repeats phrases often, does not make
eye
contact
DISCHARGE PHYSICAL EXAM
Vitals: Refusing vitals ___. No requirement for O2 >95% RA.
Weight: ___ kg
I/Os: patient not saving
General: disheveled, malodorous, shouting
CV: refused JVP examination, rrr, no murmurs, rubs, or gallops
PULM: Decreased breath sounds in lung bases bilaterally,
crackles RLL base
ABD: soft, NT, ND
EXT: trace ___ edema R>L, wwp, chronic venous stasis changes
PSYCH: pressured speech, repeats phrases often, does not make
eye
contact
Pertinent Results:
ADMISSION LABS
___ 07:25AM BLOOD WBC-12.9* RBC-4.51* Hgb-14.2 Hct-41.8
MCV-93 MCH-31.5 MCHC-34.0 RDW-17.6* RDWSD-58.8* Plt ___
___ 07:25AM BLOOD Neuts-88.0* Lymphs-4.9* Monos-6.4
Eos-0.0* Baso-0.2 Im ___ AbsNeut-11.38* AbsLymp-0.63*
AbsMono-0.82* AbsEos-0.00* AbsBaso-0.02
___ 07:25AM BLOOD Glucose-121* UreaN-15 Creat-0.8 Na-129*
K-4.3 Cl-90* HCO3-22 AnGap-17
___ 07:25AM BLOOD ___
___ 07:25AM BLOOD Calcium-8.4 Phos-3.2 Mg-1.7
___ 07:25AM BLOOD cTropnT-<0.01
___ 02:25PM BLOOD cTropnT-<0.01
INTERVAL LABS
___ 03:15PM BLOOD ALT-12 AST-17 LD(LDH)-308* AlkPhos-109
TotBili-0.6
DISCHARGE LABS
___ 08:15AM BLOOD WBC-8.1 RBC-4.49* Hgb-13.7 Hct-41.5
MCV-92 MCH-30.5 MCHC-33.0 RDW-16.0* RDWSD-54.5* Plt ___
___ 08:15AM BLOOD Glucose-94 UreaN-22* Creat-0.9 Na-137
K-4.5 Cl-97 HCO3-30 AnGap-10
___ 08:15AM BLOOD Calcium-8.8 Phos-3.9 Mg-2.0
MICROBIOLOGY
Blood culture (___): Negative
Sputum Culture (___): contamination with upper respiratory
secretions
IMAGING:
CT Chest WO Contrast (___):
1. Large, non hemorrhagic right and small left pleural
effusions; no pleural
mass or evidence of appreciable loculation. Mild pulmonary
edema.
2. Right upper and middle lobe relaxation atelectasis. No
bronchial
obstruction.
3. Nonhemorrhagic fluid collection adjacent to the right heart
could represent
loculated paramediastinal pleural effusion or postoperative
mediastinal
seroma. Small anterior mediastinal postoperative seroma.
4. Reactive mediastinal lymph nodes.
CXR (___):
1. Perihilar opacities and cardiomegaly suggest moderate
pulmonary edema.
2. Moderate right and small left pleural effusions.
3. Dense right basilar opacity may represent atelectasis or
pneumonia.
4. Cardiomegaly, with sternotomy wires.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. ALPRAZolam 0.5 mg PO DAILY:PRN anxiety
2. Amiodarone 200 mg PO DAILY
3. Atorvastatin 40 mg PO QPM
4. ClonazePAM 0.5 mg PO BID
5. FoLIC Acid 1 mg PO DAILY
6. Furosemide 60 mg PO QAM
7. Furosemide 40 mg PO QPM
8. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN dyspnea
9. PALIperidone Palmitate 234 mg IM Q1MO (MO)
10. Lisinopril 2.5 mg PO DAILY
11. Metoprolol Succinate XL 12.5 mg PO DAILY
12. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
13. Aspirin 81 mg PO DAILY
14. Lactinex (Lactobacillus acidoph-L.bulgar) 1 million cell
oral DAILY
15. Magnesium Oxide 800 mg PO BID
16. Multivitamins 1 TAB PO DAILY
17. Polyethylene Glycol 17 g PO DAILY:PRN no BMs >24 hours
Discharge Medications:
1. Torsemide 60 mg PO DAILY
RX *torsemide 20 mg 3 tablet(s) by mouth daily Disp #*90 Tablet
Refills:*0
2. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
3. ALPRAZolam 0.5 mg PO DAILY:PRN anxiety
4. Amiodarone 200 mg PO DAILY
5. Aspirin 81 mg PO DAILY
6. Atorvastatin 40 mg PO QPM
7. ClonazePAM 0.5 mg PO BID
8. FoLIC Acid 1 mg PO DAILY
9. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN dyspnea
10. Lactinex (Lactobacillus acidoph-L.bulgar) 1 million cell
oral DAILY
11. Lisinopril 2.5 mg PO DAILY
12. Magnesium Oxide 800 mg PO BID
13. Multivitamins 1 TAB PO DAILY
14. PALIperidone Palmitate 234 mg IM Q1MO (MO)
15. Polyethylene Glycol 17 g PO DAILY:PRN no BMs >24 hours
16. HELD- Metoprolol Succinate XL 12.5 mg PO DAILY This
medication was held. Do not restart Metoprolol Succinate XL
until seeing your cardiologist
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis
=================
Acute on chronic heart failure with reduced ejection fraction
Community Acquired Pneumonia
Secondary diagnosis
===================
Schizoaffective disorder, bipolar type
Atrial fibrillation
Coronary artery disease
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: History: ___ with dyspnea, reports h/o heart failure// plz
evaluate for evidence of fluid overload, infectious process
TECHNIQUE: Chest AP
COMPARISON: None
FINDINGS:
Right mid and lower lung opacity obscures the right heart border and
hemidiaphragm. Granular left and right perihilar opacities may suggest
pulmonary edema. Postoperative mediastinum with sternotomy wires numerous
surgical clips demonstrates substantial cardiomegaly. Moderate right and
small left pleural effusions. No pneumothorax.
IMPRESSION:
1. Perihilar opacities and cardiomegaly suggest moderate pulmonary edema.
2. Moderate right and small left pleural effusions.
3. Dense right basilar opacity may represent atelectasis or pneumonia.
4. Cardiomegaly, with sternotomy wires.
Radiology Report
EXAMINATION: CT CHEST W/O CONTRAST
INDICATION: ___ year old man with history of HFrEF (EF30%), CAD s/p CABG, p/w
subacute cough discolored sputum and SOB, admitted for acute on chronic CHF
exacerbation also with CAP still with O2 requirement.// ?Evaluate RLL
consolidation ?loculation ?fluid status
TECHNIQUE: Multidetector helical scanning of the chest was performed without
intravenous contrast agent and reconstructed as contiguous 5 mm and 1.25 mm
thick axial, 2.5 mm thick coronal and parasagittal, and 8 mm MIP axial images.
DOSE: Acquisition sequence:
1) Spiral Acquisition 2.6 s, 40.7 cm; CTDIvol = 10.6 mGy (Body) DLP = 429.1
mGy-cm.
Total DLP (Body) = 429 mGy-cm.
COMPARISON: None available.
FINDINGS:
NECK, THORACIC INLET, AXILLAE: The visualized thyroid is normal.
Supraclavicular and axillary lymph nodes are not enlarged.
MEDIASTINUM: Multiple mediastinal lymph nodes are measurable but not
enlarged: For example, a subaortic measures 0.9 cm (series 2, image 20) and a
pretracheal lymph node measures 0.8 cm (series 2, image 23). Nonhemorrhagic
fluid collection alonside the right lower heart (series 302, image 195) is a
loculated paramediastinal pleural effusion or postoperative mediastinal
seroma. Another small postoperative seroma is also seen in the anterior
mediastinum (series 302, image 109).
HILA: Hilar lymph nodes are not enlarged.
HEART: The heart is moderately enlarged. The patient is status post CABG
with extensive coronary artery calcification. There is no pericardial
effusion.
VESSELS: Vascular configuration is conventional. Aortic caliber is normal.
The main, right, and left pulmonary arteries are normal caliber.
Atherosclerotic calcifications of thoracic aorta is moderate.
PULMONARY PARENCHYMA: Consolidation in the anterior segment of the right
upper lobe and medial segment of the right middle lobe is consistent with
atelectasis. There is no bronchial obstruction. Bilateral septal thickening
and ground-glass opacities are are due to mild pulmonary edema. No suspicious
pulmonary nodules or mass. There is no emphysema.
AIRWAYS: The airways are patent to the subsegmental level bilaterally.
PLEURA: Bilateral non-hemorrhagic pleural effusions are large on the right
and small on the left.
CHEST WALL AND BONES: There is no worrisome lytic or sclerotic lesion.
Multilevel degenerative changes are mild. No acute fractures. Midline
sternotomy wires are intact.
UPPER ABDOMEN: Limited evaluation of the upper abdomen demonstrate vascular
calcification, but otherwise unremarkable.
IMPRESSION:
1. Large, non hemorrhagic right and small left pleural effusions; no pleural
mass or evidence of appreciable loculation. Mild pulmonary edema.
2. Right upper and middle lobe relaxation atelectasis. No bronchial
obstruction.
3. Nonhemorrhagic fluid collection adjacent to the right heart could represent
loculated paramediastinal pleural effusion or postoperative mediastinal
seroma. Small anterior mediastinal postoperative seroma.
4. Reactive mediastinal lymph nodes.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Dyspnea
Diagnosed with Heart failure, unspecified
temperature: 98.7
heartrate: 81.0
resprate: 36.0
o2sat: 92.0
sbp: 117.0
dbp: 83.0
level of pain: 0
level of acuity: 1.0 | The patient is a ___ year old homeless man currently residing in
a shelter with PMH of schizophrenia, heart failure with reduced
ejection fraction (EF 30%), CAD s/p CABG ___ with post-op
course initially complicated by persistent inotrope dependence
and new onset atrial fibrillation treated with amiodarone not on
anticoagulation. He presented with shortness of breath and cough
and found to have HFrEF exacerbation and possible RLL pneumonia
on CXR.
ACUTE ISSUES
===================
#Acute on chronic heart failure with reduced EF (30%) - Patient
initally presented with subacute history of shortness of breath
and worsening cough with productive sputum saying that there was
a respiratory infection going around his homeless shelter.
proBNP on admission 13,044 with CXR showing dense R basilar
opacity. Trigger for acute HFrEF exacerbation likely CAP.
Concern for possible non-adherence to home meds given
schizoaffective disorder, bipolar type and other multiple
psychosocial stressors including homelessness. Patient was
intermittently given lasix IV 160 boluses, however also refused
at times making diuresis difficult, though did ultimately start
accepting his IV diuresis with improvement in symptoms, clinical
exam and O2 requirement (he had no O2 requirement at time of
discharge, but wore it when in bed for comfort, so was listed in
eFlowsheets that way). CT Chest obtained showed a large R and
small L pleural effusion and moderate pulmonary edema, see below
for details. Home lisinopril 2.5mg and metoprolol succinate
12.5mg QD were held for the hospitalization due to relative
hypotension. On the day of discharge his linospril 2.5mg were
restarted. Discharged on 60mg torsemide daily. Metoprolol was
held at discharge to be restarted at a later date if
appropriate. DISCHARGE WEIGHT 55.9kg.
#Pleural effusion:
CT Chest obtained showed a large R and small L pleural effusion
and moderate pulmonary edema. Consulted IP who recommended
diagnostic thoracentesis. Patient refused procedure. Did not
have capacity, but clearly voiced that did not want needle in
his back. Spoke to guardian ___ (___),
explained that based on CT and ultrasound performed by
pulmonary, effusion was likely not complicated and drainage was
not definitely necessary, and may not change management. Though
it was explained that without pleural fluid analysis we would
not know for sure if it was complicated, and would not know if
this was malignant, transudative or infectious. Based on this
conversation, the guardian did not want to sedate patient
against his will to perform this. This is consistent with her
previous decisions regarding medical care for the patient. As
per discussions with guardian, would not want patient to be
sedated for medications and given CT and US did not show
evidence of complicated effusion, would not want to force
sedation on patient for the procedure against his will. Decision
was made not to pursue thoracentesis and patient was
intermittently diuresed with lasix boluses with improvement in
shortness of breath.
#Guardianship/capacity: Patient evaluated by psychiatry and
found not to have capacity. Current active guardian is ___
___ (___) who was actively involved during this
admission. She was easily reached at the above cell number. See
above for decisions regarding the pleural effusion and
medication compliance.
#CAP - Given cough with productive sputum and CXR showing RLL
opacity, patient was treated with 5 day course of CTX and
azithromycin for CAP.
#Schizoaffective disorder, bipolar type - Psychiatry was
consulted and it was determined patient has schizoaffective
disorder bipolar type and did not have capacity. Attempted to
give paliperidone 156mg IM and Depakote however patient was
refusing so order was discontinued.
#Hyponatremia - Initially presented with Na 129, likely
hypervolemic in setting of CHF exacerbation. Uptrended to normal
with diuresis.
CHRONIC ISSUES
================
#Afib: - CHADS2-VASC score 3. Not on anticoagulation given
history of bilateral IPH and SDH in ___ and potential for
non-compliance given history of mental illness. Occurred as
complication after CABG. In NSR on EKG. Continued amiodarone
200mg daily.
#CAD s/p CABG ___: continued metoprolol as above,
atorvastatin 40mg daily, and ASA 81mg daily
TRANSITIONAL ISSUES
==================
[ ] New medications - Patient was started on torsemide 60mg PO
QDaily
[ ] Stopped medications - Home furosemide 60 QAM and 60 QPM were
discontinued and replaced with PO Torsemide, metoprolol held on
discharge
[ ] consider adding back metoprolol if able
[ ] Volume exam and renal function cardiology NP appointment on
___ and/or PCP appointment on ___, consider adjusting
[ ] Consider repeat CXR in ___ weeks to evaluate interval change
in size of R pleural effusion
[ ] If patient becomes more short of breath may need
re-evaluation for drainage of pleural effusion
[ ] Discharge weight 55.9kg
Communication: Guardian ___ (___),
Code: Full Code |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
adhesive tape
Attending: ___.
Chief Complaint:
Disc Herniation
Major Surgical or Invasive Procedure:
L5-S1 TILF
History of Present Illness:
Recent revision microdiscectomy with Dr. ___ on ___
4 days of worsening pain, MRI with recurrent hernitation now s/p
L5-S1 TLIF
Past Medical History:
disc herniation
Social History:
___
Family History:
___
Physical Exam:
98.7
PO 103 / 65
L Lying 87 20 96 Ra
NAD, A&Ox4
nl resp effort
RRR
Sensory:
___
L2 L3 L4 L5 S1 S2
(Groin) (Knee) (Med Calf) (Grt Toe) (Sm Toe) (Post Thigh)
R SILT SILT SILT SILT SILT SILT
L SILT SILT SILT SILT SILT SILT
Motor:
___ Flex(L1) Add(L2) Quad(L3) TA(L4) ___ ___
R 5 5 5 5 5 5 5
L 5 5 5 5 5 5 5
Pertinent Results:
___ 05:20PM GLUCOSE-100 UREA N-18 CREAT-1.1 SODIUM-137
POTASSIUM-4.5 CHLORIDE-98 TOTAL CO2-28 ANION GAP-11
___ 05:20PM estGFR-Using this
___ 05:20PM WBC-9.7 RBC-4.89 HGB-14.5 HCT-41.9 MCV-86
MCH-29.7 MCHC-34.6 RDW-12.1 RDWSD-37.8
___ 05:20PM NEUTS-66.2 ___ MONOS-5.1 EOS-4.7
BASOS-0.5 IM ___ AbsNeut-6.42* AbsLymp-2.24 AbsMono-0.50
AbsEos-0.46 AbsBaso-0.05
___ 05:20PM PLT COUNT-177
Medications on Admission:
see omr
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
RX *acetaminophen 500 mg 2 capsule(s) by mouth q___ prn Disp #*90
Capsule Refills:*0
2. Bisacodyl 10 mg PO/PR DAILY
RX *bisacodyl 5 mg 2 tablet(s) by mouth daily Disp #*60 Tablet
Refills:*0
3. Diazepam 5 mg PO BID:PRN pain
RX *diazepam 5 mg 1 tab by mouth BID PRN Disp #*60 Tablet
Refills:*0
4. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
5. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone [Oxaydo] 5 mg 1 tablet(s) by mouth q4-6h prn Disp
#*60 Tablet Refills:*0
6. Senna 8.6 mg PO BID
RX *sennosides [senna] 8.6 mg 1 tab by mouth daily Disp #*30
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Recurrent disc herniation
Discharge Condition:
stable
Followup Instructions:
___
Radiology Report
EXAMINATION: LUMBAR SINGLE VIEW IN OR
INDICATION: POST. L5-S1 FUSION
TECHNIQUE: Frontal and lateral view radiographs of the lumbar spine.
COMPARISON: X-rays ___
FINDINGS:
2 intraoperative images of the lumbar spine were obtained during L5-S1 fusion.
On the first image markers are seen at the L5-S1 level. Instruments and
orthopedic hardware is evident. Please refer to the operative report.
IMPRESSION:
Intraoperative images lumbar spine.
Radiology Report
EXAMINATION: LUMBO-SACRAL SPINE (AP AND LAT)
INDICATION: ___ year old man with L5-S1 fusion// post op post op
TECHNIQUE: Frontal and lateral view radiographs of the lumbar spine.
COMPARISON: Intraoperative images dated ___
FINDINGS:
5 non-rib-bearing lumbar vertebral bodies are present. The patient is status
post posterior fusion of L5 and S1 as well as placement of an interbody
spacer. A skin staples project over the subcutaneous tissues at midline. A
drain is present.
The alignment is maintained as are the vertebral body heights. There is no
evidence of acute hardware related complications. A substantial amount of
stool and gas project throughout the colon.
IMPRESSION:
Postoperative changes as described above. No acute hardware related
complication is identified.
Substantial stool burden.
Radiology Report
EXAMINATION: LUMBO-SACRAL SPINE (AP AND LAT)
INDICATION: ___ year old man s/p L5/S1 TLIF, drain pulled out inadvertently//
evaluation for retained drain evaluation for retained drain
TECHNIQUE: Frontal and lateral view radiographs of the lumbar spine.
COMPARISON: ___
FINDINGS:
The drain has been removed. There is no evidence of a retained drain within
the subcutaneous tissues of the back. Skin staples are still present. The
alignment of the lumbar spine is unchanged. There is no evidence of acute
hardware related complications. Interval decrease in the amount of stool seen
throughout the colon.
IMPRESSION:
No radiographic evidence of a retained portion of the drain.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Back pain, Wound eval
Diagnosed with Low back pain
temperature: 98.8
heartrate: 87.0
resprate: 18.0
o2sat: 98.0
sbp: 115.0
dbp: 94.0
level of pain: 5
level of acuity: 3.0 | Patient was admitted to the ___ Spine Surgery Service and
taken to the Operating Room for an L5/S1 TLIF. Refer to the
dictated operative note for further details. The surgery was
without complication and the patient was transferred to the PACU
in a stable condition. TEDs/pnemoboots were used for
postoperative DVT prophylaxis. Intravenous antibiotics were
continued for 24hrs postop per standard protocol. Initial postop
pain was controlled with a IV and PO pain medications. Diet was
advanced as tolerated. The patient was transitioned to oral
pain medication when tolerating PO diet. Foley was removed
postoperatively without issue. Physical therapy was consulted
for mobilization OOB to ambulate. Hospital course was otherwise
unremarkable. On the day of discharge the patient was afebrile
with stable vital signs, comfortable on oral pain control and
tolerating a regular diet. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: EMERGENCY
Allergies:
nafcillin / piperacillin
Attending: ___.
Chief Complaint:
Dyspnea & Hypoxemia
Major Surgical or Invasive Procedure:
MULTIPLE BRONCHOSCOPY/BAL
___: PERCUTANEOUS PLACEMENT OF J TUBE:
History of Present Illness:
Mr. ___ is a ___ with PMHx of C4 quadriplegia secondary to
a football accident ___ years ago, Hx of hyponatremia (Na
125-130 ___ ___, ?CAD per chart, multiple UTIs, and other
issues who was transferred from an OSH after presenting with
dypsnea. He describes URI sypmtoms starting 4 days ago which
progressed to cough with dyspnea. He went to an urgent care
center, where pt reports a CXR was negative for pneumonia.
Nevertheless, he was started on azithromycin, possibly for
bronchitis vs. URI (___). Despite this he required
increasing frequency of albuterol nebulizers at home, and his
father reports increasing cough with mucous production,
requiring quad cough assistance. Last night, he developed
respiratory distress and was brought by ambulance to an OSH.
There, he was tachypneic and hypoxemic on NC but reportedly
satting well on ventimask. He was found to have Na 101, K 2.8,
Mg 1.0 and unilateral L whiteout noted on CXR. Other labs
include TropI <0.015, lactate 1.4, WBC 5.9, Plt 170, Na+ 102 @
05:10am, Ddimer 2.02 (elevated, RR 0.19-0.5 mg/L), Alb 2.6, AST
140, ALT 91, ALP 181, and CPK 643. He was given Zosyn and
Azithromycin for pneumonia ___ a total volume of 350 cc's D5W),
Duonebs, 3g Mg, and 40mEq K. He received a total of 450 cc's of
normal saline at the OSH. UOP there was 4.1 L. Mental status
was reportedly completely normal with no report of seizure, but
he was started on 500 cc's of 3% saline at 20 cc's/hr through a
PIV prior to transfer.
On arrival to the ___ ED, he reported feeling fatigued and
dyspneic without much change ___ his sypmtoms since his initial
presentation. ___ the ED, intial VS were 97.5 71 118/86 22 96%
6L. Exam notable for mental status alert and oriented but
sleepy, speaking ___ full sentences. He appeared euvolemic. He
was tachypneic with ronchi throughout and some wheezing. His
abdomen was quite distended; bedside US revealed a large
bladder, so a foley catheter was placed. Labs were notable for
Na 102, K 2.8, Cl 66, BUN/Cr ___, serum osms 207, urine Na 30,
urine osms 208. CBC w/ normal WBCs but 21% bands. CXR showed a
large L opacity with evidence of volume loss and no clear air
bronchograms, suggestive of collapsed lung, with patchy alveolar
infiltrates at the R base. EKG showed NSR @ 70 bpm, normal
axis, no T wave changes, no ST segment changes. His hypertonic
saline was stopped (unclear how much he received; reportedly bag
was still mostly full). He received NS w/ 40 mEq K @ 150
cc's/hr and 40 mEq PO K, and was admitted to the ICU for
hypoxemia and hyponatremia. VS prior to transfer were 96.8 65
156/99 26 89-91% NC.
On arrival to the ICU, patient was sleepy but AOx3 and reported
feeling anxious but with stable breathing. UOP was 400 cc's ___
the first hour, with an addittional 1.5L emptied ___ our ED. His
parents report that his mental status has been slightly altered
since ___. He has had minimal PO intake of food since
then but has been drinking water, estimating his intake at ~20
oz per day.
Past Medical History:
-C4 quadriplegia ___ football accident ___ ___ (had a
tracheostomy during that hospitalization, and reportedly also
had DVT/PE requiring IVC filter placement, still be ___ place.
Also had PNA during that hospitalizaiton; no pneumonias since.
Does CIC BID for neurogenic bladder and digital stimulation for
bowel movements).
-Hx of multiple UTIs (does not have indwelling foley; uses clean
intermittent catheter BID at home, usually emptying 1200-1500
cc's BID, and a condom cath at night)
-Orthostatic hypotension (BP usually ___
-Hyponatremia (Na 125 ___ ___, per pt has been 120s-130s; PCP
with no labs on record)
-Hx of Dysphagia at the time of spinal cord injury
-?CAD
-Pernicious anemia
Social History:
___
Family History:
deferred
Physical Exam:
Admission Physical Exam:
GENERAL: Alert but sleepy and with slowed speech. AOx3, ___ mild
respiratory distress; belly breathing and speaking ___ short
phrases.
HEENT: Sclera anicteric, oropharynx clear, mucous membranes
moistr
NECK: Old tracheostomy scar present. No appreciable JVD.
LUNGS: Absent breath sounds at L base, good air movement on the
R. No wheezes anteriorly. Diffuse ronchi posteriorly.
CV: Regular rate and rhythm, no murmurs/rubs/gallops
ABDOMEN: soft, non-tender, non-distended, bowel sounds quiet, no
rebound tenderness or guarding, no organomegaly
GU: + Foley ___ place
EXTR: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
NEURO: Paraparesis ___ bilat LEs and RUE, LUE with flexion
contracture and some residual movement
SKIN: warm, dry, no rashes or lesions
DISCHARGE PHYSICAL:
GENERAL: Alert and oriented x3. NAD
HEENT:Sclera anicteric, oropharynx clear, mucous membranes
moistr
NECK: Trach site looks clean and ___ place
LUNGS: Coarse breath sounds bilaterally
CV: Regular rate and rhythm, no murmurs/rubs/gallops
ABDOMEN: soft, non-tender, non-distended, bowel sounds quiet, no
rebound tenderness or guarding, no organomegaly
GU: + Foley ___ place
EXTR: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
NEURO: Paraparesis ___ bilat LEs and RUE, LUE with flexion
contracture and some residual movement
SKIN: warm, dry, no rashes or lesions
Pertinent Results:
Admission Labs:
================================================
___ 09:01PM GLUCOSE-104* UREA N-7 CREAT-0.4* SODIUM-107*
POTASSIUM-4.2 CHLORIDE-75* TOTAL CO2-26 ANION GAP-10
___ 09:01PM CALCIUM-7.4* PHOSPHATE-1.1* MAGNESIUM-1.9
___ 09:01PM OSMOLAL-223*
___ 04:42PM GLUCOSE-83 UREA N-7 CREAT-0.3* SODIUM-103*
POTASSIUM-3.6 CHLORIDE-72* TOTAL CO2-24 ANION GAP-11
___ 04:42PM CALCIUM-7.3* PHOSPHATE-1.3* MAGNESIUM-2.0
___ 04:42PM OSMOLAL-215*
___ 11:42AM GLUCOSE-101* UREA N-6 CREAT-0.3* SODIUM-102*
POTASSIUM-3.6 CHLORIDE-67* TOTAL CO2-27 ANION GAP-12
___ 11:42AM CALCIUM-7.5* PHOSPHATE-1.6* MAGNESIUM-1.6
___ 11:42AM OSMOLAL-205*
___ 08:57AM ___ COMMENTS-GREEN TOP
___ 08:57AM GLUCOSE-127* LACTATE-2.2* NA+-102* K+-2.8*
CL--66* TCO2-27
___ 08:57AM HGB-11.3* calcHCT-34
___ 08:55AM URINE HOURS-RANDOM CREAT-16 SODIUM-30
POTASSIUM-26 CHLORIDE-34 CALCIUM-4.3 URIC ACID-18.6
___ 08:55AM URINE OSMOLAL-208
___ 08:55AM URINE COLOR-Straw APPEAR-Hazy SP ___
___ 08:55AM URINE BLOOD-SM NITRITE-NEG PROTEIN-TR
GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-TR
___ 08:55AM URINE RBC-1 WBC-4 BACTERIA-MANY YEAST-NONE
EPI-<1
___ 08:55AM URINE AMORPH-FEW
___ 08:55AM URINE MUCOUS-OCC
___ 08:50AM OTHER BODY FLUID FluAPCR-NEGATIVE
FluBPCR-NEGATIVE
___ 08:30AM GLUCOSE-130* UREA N-5* CREAT-0.4* SODIUM-101*
POTASSIUM-3.2* CHLORIDE-64* TOTAL CO2-23 ANION GAP-17
___ 08:30AM estGFR-Using this
___ 08:30AM ALT(SGPT)-105* AST(SGOT)-161* ALK PHOS-168*
TOT BILI-0.7
___ 08:30AM proBNP-1026*
___ 08:30AM ALBUMIN-3.4* CALCIUM-8.0* PHOSPHATE-1.7*
MAGNESIUM-1.8 URIC ACID-1.9*
___ 08:30AM WBC-6.3 RBC-3.78* HGB-11.2* HCT-29.8* MCV-79*
MCH-29.6 MCHC-37.4* RDW-15.0
___ 08:30AM NEUTS-72* BANDS-21* LYMPHS-2* MONOS-3 EOS-0
BASOS-0 ATYPS-2* ___ MYELOS-0
___ 08:30AM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-1+
MACROCYT-NORMAL MICROCYT-OCCASIONAL POLYCHROM-OCCASIONAL
OVALOCYT-OCCASIONAL BURR-1+
___ 08:30AM PLT SMR-NORMAL PLT COUNT-152
___ 08:30AM ___ PTT-30.2 ___
MICROBIOLOGY:
================================================
SPUTUM
___ 6:00 am SPUTUM Source: Endotracheal.
**FINAL REPORT ___
GRAM STAIN (Final ___:
___ PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
___ CLUSTERS.
RESPIRATORY CULTURE (Final ___:
RARE GROWTH Commensal Respiratory Flora.
STAPH AUREUS COAG +. SPARSE GROWTH. OF TWO COLONIAL
MORPHOLOGIES. Oxacillin RESISTANT Staphylococci MUST be reported
as also
RESISTANT to other penicillins, cephalosporins, carbacephems,
carbapenems, and beta-lactamase inhibitor combinations. Rifampin
should not be used alone for therapy. SENSITIVIES CONFIRMED BY
REPEAT ___.
CEFOXITIN sensitivity testing confirmed by ___.
YEAST.SPARSE GROWTH.
SENSITIVITIES: MIC expressed ___ MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ <=0.5 S
RESPIRATORY CULTURE (Final ___:
~5000/ML Commensal Respiratory Flora.
STAPH AUREUS COAG +. ~8OOO/ML.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN-------------<=0.25 S
TETRACYCLINE---------- 2 S
TRIMETHOPRIM/SULFA---- <=0.5 S
___ 9:11 pm SPUTUM Source: Endotracheal.
**FINAL REPORT ___
GRAM STAIN (Final ___:
___ PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final ___:
Commensal Respiratory Flora Absent.
YEAST. SPARSE GROWTH.
KLEBSIELLA PNEUMONIAE. RARE GROWTH.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
STAPH AUREUS COAG +. RARE GROWTH.
SENSITIVITIES PERFORMED ON CULTURE # ___ ON
___.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
___ 11:58 am SPUTUM Source: Endotracheal.
**FINAL REPORT ___
GRAM STAIN (Final ___:
<10 PMNs and <10 epithelial cells/100X field.
2+ ___ per 1000X FIELD): GRAM NEGATIVE ROD(S).
1+ (<1 per 1000X FIELD): BUDDING YEAST.
QUALITY OF SPECIMEN CANNOT BE ASSESSED.
RESPIRATORY CULTURE (Final ___:
Due to mixed bacterial types ( >= 3 colony types) an
abbreviated
workup will be performed appropriate to the isolates
recovered from
this site.
Commensal Respiratory Flora Absent.
___. ___ (___) REQUESTED FOR THE GRAM NEGATIVE
RODS WORK UP
ON ___.
YEAST. SPARSE GROWTH.
KLEBSIELLA PNEUMONIAE. RARE GROWTH.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
KLEBSIELLA PNEUMONIAE. RARE GROWTH ___ MORPHOLOGY.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
| KLEBSIELLA PNEUMONIAE
| |
AMPICILLIN/SULBACTAM-- 4 S 4 S
CEFAZOLIN------------- <=4 S <=4 S
CEFEPIME-------------- <=1 S <=1 S
CEFTAZIDIME----------- <=1 S <=1 S
CEFTRIAXONE----------- <=1 S <=1 S
CIPROFLOXACIN---------<=0.25 S <=0.25 S
GENTAMICIN------------ <=1 S <=1 S
MEROPENEM-------------<=0.25 S <=0.25 S
PIPERACILLIN/TAZO----- <=4 S <=4 S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- <=1 S <=1 S
___ 1:45 pm SPUTUM Source: Expectorated.
**FINAL REPORT ___
GRAM STAIN (Final ___:
___ PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): YEAST(S).
RESPIRATORY CULTURE (Final ___:
Commensal Respiratory Flora Absent.
YEAST. SPARSE GROWTH.
KLEBSIELLA PNEUMONIAE. RARE GROWTH.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
___ 10:06 am SPUTUM Source: Endotracheal.
**FINAL REPORT ___
GRAM STAIN (Final ___:
>25 PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final ___:
Commensal Respiratory Flora Absent.
KLEBSIELLA PNEUMONIAE. SPARSE GROWTH.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
YEAST. SPARSE GROWTH.
KLEBSIELLA PNEUMONIAE. SPARSE GROWTH.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h. ___ MORPHOLOGY.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
| KLEBSIELLA PNEUMONIAE
| |
AMPICILLIN/SULBACTAM-- 4 S <=2 S
CEFAZOLIN------------- <=4 S <=4 S
CEFEPIME-------------- <=1 S <=1 S
CEFTAZIDIME----------- <=1 S <=1 S
CEFTRIAXONE----------- <=1 S <=1 S
CIPROFLOXACIN---------<=0.25 S <=0.25 S
GENTAMICIN------------ <=1 S <=1 S
MEROPENEM-------------<=0.25 S <=0.25 S
PIPERACILLIN/TAZO----- <=4 S <=4 S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- <=1 S <=1 S
BRONCHOALVEOLAR LAVAGE
BAL ___ 3:13 pm Rapid Respiratory Viral Screen & Culture
BRONCHIAL LAVAGE.
**FINAL REPORT ___
Respiratory Viral Culture (Final ___: OSITIVE FOR
RESPIRATORY VIRUSES. Reported to and read back by ___. ___
___ 10:30AM ___.
ADENOVIRUS. CONFIRMED BY MONOCLONAL FLUORESCENT ANTIBODY..
Sputum ___ 9:11 pm SPUTUM Source: Endotracheal.
**FINAL REPORT ___
GRAM STAIN (Final ___ PMNs and <10 epithelial
cells/100X field. NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final ___: Commensal Respiratory
Flora Absent.
YEAST. SPARSE GROWTH. KLEBSIELLA PNEUMONIAE. RARE GROWTH.
Cefazolin interpretative criteria are based on a dosage regimen
of 2g every 8h. STAPH AUREUS COAG +. RARE GROWTH.
SENSITIVITIES PERFORMED ON CULTURE # ___ ON ___.
SENSITIVITIES: MIC expressed ___ MCG/MG
______________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
___ 5:08 pm BRONCHOALVEOLAR LAVAGE BRONCHIAL LAVAGE.
**FINAL REPORT ___
GRAM STAIN (Final ___:
3+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final ___: NO GROWTH, <1000
CFU/ml.
___ 5:53 pm BRONCHOALVEOLAR LAVAGE BRONCHIAL LAVAGE.
**FINAL REPORT ___
GRAM STAIN (Final ___:
2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final ___:
Commensal Respiratory Flora Absent.
YEAST. ___.
___ 5:00 pm BRONCHOALVEOLAR LAVAGE
**FINAL REPORT ___
GRAM STAIN (Final ___:
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
3+ ___ per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND CHAINS.
RESPIRATORY CULTURE (Final ___:
>100,000 ORGANISMS/ML. Commensal Respiratory Flora.
KLEBSIELLA PNEUMONIAE. 10,000-100,000 ORGANISMS/ML..
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
GRAM NEGATIVE ROD #2. ~1000/ML. FURTHER WORKUP ON
REQUEST ONLY.
Isolates are considered potential pathogens ___ amounts
>=10,000
cfu/ml.
YEAST. ~3000/ML.
Isolates are considered potential pathogens ___ amounts
>=10,000
cfu/ml.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
___ 2:46 pm BRONCHOALVEOLAR LAVAGE LINGULA BAL.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Preliminary):
___ Commensal Respiratory Flora.
Further workup requested by ___ ___ (___) ___.
KLEBSIELLA PNEUMONIAE. 10,000-100,000 ORGANISMS/ML..
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
___
___.
GRAM NEGATIVE ROD #2. ~3000/ML. FURTHER WORKUP ON
REQUEST ONLY.
Isolates are considered potential pathogens ___ amounts
>=10,000
cfu/ml.
YEAST. ___.
Isolates are considered potential pathogens ___ amounts
>=10,000
cfu/ml.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary):
MICROBIOLOGY SEROLOGIES
___ CMV BLOOD IgG/IgM Ab negative
___ EBV BLOOD IgG Ab positive, IgM Ab negative
___ 12:21 pm CATHETER TIP-IV Source: ___.
**FINAL REPORT ___
WOUND CULTURE (Final ___: No significant growth.
BLOOD CX NEGATIVE (DATED ___ X 2, ___ 2, ___,
___ X 2, ___ X 2, ___ X2)
___ BLOOD CX PENDING
URINE CX NEGATIVE/CONTAMINATED (DATED ___,
___ 2:41 am URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___:
YEAST. 10,000-100,000 ORGANISMS/ML..
___ LEGIONALLA URINARY ANTIGEN NEGATIVE
___ C DIFF STOOL ANTIGEN NEGATIVE
___ C DIFF STOOL ANTIGEN NEGATIVE
RAPID RESPIRATORY VIRAL SCREEN & CULTURE
___ 3:13 pm Rapid Respiratory Viral Screen & Culture
BRONCHIAL LAVAGE.
**FINAL REPORT ___
Respiratory Viral Culture (Final ___:
POSITIVE FOR RESPIRATORY VIRUSES.
Reported to and read back by ___. ___ 10:30AM
___.
ADENOVIRUS. CONFIRMED BY MONOCLONAL FLUORESCENT
ANTIBODY..
Reported to and read back by ___ ___
2:26PM.
Respiratory Viral Antigen Screen (Final ___:
Less than 60 columnar epithelial cells;.
Inadequate specimen for DFA detection of respiratory
viruses..
Interpret all negative DFA and/or culture results from
this specimen
with caution..
Negative results should not be used to discontinue
precautions..
Recommend new sample be submitted for confirmation..
Refer to respiratory viral culture and/or Influenza PCR
(results
listed under "OTHER" tab) for further information..
Reported to and read back by ___ (4I) ___
___ 5:08 pm Rapid Respiratory Viral Screen & Culture
BRONCHIAL LAVAGE.
**FINAL REPORT ___
Respiratory Viral Culture (Final ___:
ADENOVIRUS. CONFIRMED BY MONOCLONAL FLUORESCENT
ANTIBODY..
Respiratory Viral Antigen Screen (Final ___:
Greater than 400 polymorphonuclear leukocytes;.
Inadequate specimen for DFA detection of respiratory
viruses..
Interpret all negative DFA and/or culture results from
this specimen
with caution..
Negative results should not be used to discontinue
precautions..
Refer to respiratory viral culture and/or Influenza PCR
(results
listed under "OTHER" tab) for further information..
___ 2:43 pm Rapid Respiratory Viral Screen & Culture
Source: Nasopharyngeal swab.
**FINAL REPORT ___
Respiratory Viral Culture (Final ___:
No respiratory viruses isolated.
Culture screened for Adenovirus, Influenza A & B,
Parainfluenza type
1,2 & 3, and Respiratory Syncytial Virus..
Detection of viruses other than those listed above will
only be
performed on specific request. Please call Virology at
___
within 1 week if additional testing is needed.
Respiratory Viral Antigen Screen (Final ___:
Negative for Respiratory Viral Antigen.
Specimen screened for: Adeno, Parainfluenza 1, 2, 3,
Influenza A, B,
and RSV by immunofluorescence.
Refer to respiratory viral culture and/or Influenza PCR
(results
listed under "OTHER" tab) for further information..
IMAGING
================================================
CXR (___):
Extensive left lung opacification concerning for pneumonia.
Right lower lung reticular opacities may reflect aspiration or
pneumonia. Probable moderate left pleural effusion. Recommend
followup to resolution.
CXR (___):
Generalized improvement ___ background lung density concurrent
with mild
decrease ___ heart size suggests improvement ___ the component of
pulmonary
edema, but considerable abnormality remains, particular
bibasilar
consolidation due to infection or hemorrhage. Left pleural
effusion is
probably moderate ___ size, unchanged. There is no pneumothorax.
ET tube is ___ standard placement, transesophageal drainage tube
passes into
the stomach and out of view. Left PIC line ends ___ the mid SVC.
CXR (___):
___ comparison with the study of ___, there is little
overall change.
Monitoring and support devices remain ___ place. Bibasilar at
areas of
opacification are again seen. On the left, poor definition of
the
hemidiaphragms suggests substantial volume loss ___ the left
lower lobe. Again,
however, ___ the appropriate clinical setting it would be
difficult to
definitely exclude superimposed pneumonia.
The contrast material ___ the the esophagus is not definitely
appreciated on
this study.
CT ABD/PELVIS (___):
IMPRESSION:
1. Normal appearing liver.
2. Small, focal dissection ___ the abdominal aorta, extending
from below the right renal artery to the right common iliac
artery. No evidence of end organ ischemia.
3. Thickened bladder. While this may represent a neurogenic
bladder,
correlation with urinalysis is recommended to exclude acute on
chronic
cystitis.
4. Trace amount of ascites, non drainable.
5. Findings ___ the chest reported separately.
CT CHEST W/CONTRAST (___):
IMPRESSION:
1. Bilateral pulmonary opacities, some of which are
consolidative, some of which are ground-glass, and some of which
are ___, are ___ keeping with the history of a Staph
pneumonia. The different opacities likely represent the
infectious process at different levels of maturity. Of note, one
opacity at the right apex has a small central cavitation.
2. Mediastinal and left hilar lymphadenopathy. This is likely
reactive, though a repeat chest CT is recommended after
treatment to ensure resolution of both the opacities and this
lymphadenopathy.
CTA TORSO (___):
-Unchanged appearance of focal dissection extending from below
the right renal
artery to the right common iliac arterial ostium.
-More confluent solid/ground-glass opacification of the right
middle and lower
lobes compared to prior study. Numerous solid/ground-glass
pulmonary nodules
are again demonstrated within the visualized lungs, consistent
with history of
pneumonia. New moderate left subpulmonic effusion.
-Mediastinal adenopathy, likely reactive.
-Marked bladder wall thickening, possibly representing cystitis.
Mild
prominence of retroperitoneal nodes, possibly reactive.
- Other findings as detailed above.
CTA CHEST (___):
1. No evidence of pulmonary embolism to the segmental level.
Evaluation of
the subsegmental pulmonary arteries is limited by respiratory
motion.
2. Interval improvement ___ multifocal pneumonia with persistent
left lower
lobe consolidation.
3. Unchanged cavitary nodule ___ the right lung apex.
4. Stable mediastinal lymphadenopathy, likely reactive.
5. ET tube with secretions above the cuff.
ECHO ___:
The left atrium is normal ___ size. No atrial septal defect is
seen by 2D or color Doppler. The estimated right atrial pressure
is ___ mmHg. Left ventricular wall thickness, cavity size and
regional/global systolic function are normal (LVEF = 65%).
Tissue Doppler imaging suggests a normal left ventricular
filling pressure (PCWP<12mmHg). Right ventricular chamber size
and free wall motion are normal. The aortic valve leaflets (3)
appear structurally normal with good leaflet excursion and no
aortic stenosis or aortic regurgitation. The mitral valve
appears structurally normal with trivial mitral regurgitation.
The estimated pulmonary artery systolic pressure is normal.
There is no pericardial effusion.
___: RUE U/S
No evidence of deep vein thrombosis ___ the right upper
extremity.
___: VIDEO OROPHARYNGEAL SWALLOW:
Aspiration of thin, nectar, and honey thick liquids.
___: PERCUTANEOUS PLACEMENT OF J TUBE: Successful placement of
a 16 ___ MIC gastrojejunostomy tube with its tip ___
the proximal jejunum. The gastric port should not be used for 24
hours.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Midodrine 10 mg PO TID
2. Azithromycin 250 mg PO Q24H
3. methenamine hippurate 1 gram oral BID bladder spasm
4. Pseudoephedrine 30 mg PO Q6H:PRN hypotension
Discharge Medications:
1. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 7 Days
Stop date ___
2. Senna 8.6 mg PO BID:PRN Constipation
3. Sarna Lotion 1 Appl TP QID:PRN rash/itching
4. Polyethylene Glycol 17 g PO DAILY
5. Albuterol 0.083% Neb Soln 1 NEB IH Q6H
6. Midodrine 10 mg PO TID
7. Midodrine 12.5 mg PO QHS
8. Acetylcysteine 20% ___ mL NEB Q6H:PRN To be used with
albuterol or to help with secretions
9. Albuterol 0.083% Neb Soln 1 NEB IH Q2H:PRN SOB
to be given for break through shortness of breath if needed
10. Albuterol Inhaler ___ PUFF IH Q4H
11. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
12. Atropine Sulfate 0.5-1 mg IV ONCE:PRN bradycardia
13. Bisacodyl 10 mg PO/PR DAILY Constipation
14. Chloraseptic Throat Spray 1 SPRY PO Q4H:PRN discomfort from
ET tube
15. ClonazePAM 1 mg PO TID:PRN anxiety, insomnia
16. Dextromethorphan-Guaifenesin (Sugar Free) 10 mL PO Q6H:PRN
cough
17. Docusate Sodium (Liquid) 100 mg PO BID
18. Famotidine 20 mg PO Q12H
19. Glycopyrrolate 1 mg PO BID
20. Miconazole Powder 2% 1 Appl TP QID:PRN rash on buttocks
21. Nystatin Oral Suspension 5 mL PO QID:PRN thrush
22. OLANZapine 5 mg PO QHS:PRN insomnia
23. Methenamine Hippurate 1 gram ORAL BID bladder spasm
24. Pseudoephedrine 30 mg PO Q6H:PRN hypotension
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Trach/Peg placement
Respiratory distress
Pneumonia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Followup Instructions:
___
Radiology Report
EXAMINATION: AP chest x-ray.
INDICATION: A ___ man with a cough, hypoxic, outside hospital
transfer with report of white out, evaluate for pneumonia or pleural effusion.
TECHNIQUE: AP chest radiographs.
COMPARISON: Outside hospital chest radiograph ___ at 04:20.
FINDINGS:
There is significant leftward rotation of the patient on current radiograph.
Allowing for changes due to this, the cardiomediastinal silhouette is
unchanged from same-day outside hospital chest radiograph. Extensive left lung
opacification limits full evaluation of the cardiac silhouette, which appears
normal. There is no evidence of pulmonary vascular congestion or pulmonary
edema. Extensive consolidation with air bronchograms involving the majority of
the left lung is concerning for pneumonia. More ill-defined reticular
opacities within the right lower lung may reflect sequela of aspiration or
pneumonia. Underlying emphysema is suspected. There is no right pleural
effusion. There is likely at least a moderate left pleural effusion. There is
no pneumothorax.
IMPRESSION:
Extensive left lung opacification concerning for pneumonia. Right lower lung
reticular opacities may reflect aspiration or pneumonia. Probable moderate
left pleural effusion. Recommend followup to resolution.
Radiology Report
EXAMINATION: CHEST PORT. LINE PLACEMENT
INDICATION: ___ year old man with L new PICC // Evaluate L new PICC 46cm
___ ___ Contact name: ___: ___ Evaluate L new PICC 46cm
___ ___
IMPRESSION:
In comparison with the earlier study of this date, there has been placement of
a left subclavian PICC line that extends to the mid to lower portion of the
SVC. Little change in the appearance of the heart and lungs.
NOTIFICATION: ___, a venous access nurse.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with LLL PNA - intubated // eval for ETT
placement eval for ETT placement
IMPRESSION:
In comparison with the earlier study of this day, there has been placement of
an endotracheal tube with its tip approximately 5 cm above the carina.
Nasogastric tube is in the stomach, though the side hole is probably just
proximal to the esophagogastric junction. Otherwise little change.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: interval changes
TECHNIQUE: Semi upright portable AP radiograph of the chest was obtained.
COMPARISON: Frontal chest radiograph ___.
FINDINGS:
There is an endotracheal tube with tip terminating approximately 5.7 cm
cephalad to the carinal. There is nasogastric tube with tip terminating below
the diaphragm. There is a left PICC with tip terminating in the lower
superior vena cava.
There is improved aeration of the left hemi thorax with decrease in size of
left layering pleural effusion. There is marked increase aeration of the left
upper lung.
There is irregularity and enlargement of the left hilum the right hilum and
right lung are unremarkable. There is no evidence of pneumothorax.
Cardiomediastinal silhouette and pulmonary vasculature are within normal
limits.
IMPRESSION:
1. Improved aeration of the left lung with decrease in size of the layering
left pleural effusion.
2. Enlargement and irregularity of the left hilum. CT scan is recommended for
further evaluation.
NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___
in person on ___ at 9:00 AM, at the time of discovery.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with hypoxemia s/p bronch broad antibiotics
persistent fevers. // fevers? fevers?
TECHNIQUE: Portable AP frontal chest radiograph was obtained.
COMPARISON: Frontal chest radiograph ___.
FINDINGS:
Endotracheal tube tip projects 6.9 cm cephalad to the carina. Left PICC tip
projects over the low superior vena cava. Nasogastric tip projects below the
diaphragm, however the side hole projects at the level of the gastroesophageal
junction.
Layering left pleural effusion is unchanged. Left mid and upper lung opacities
have increased. Diffuse interstitial markings throughout the remaining lungs
are unchanged. Heart size is not enlarged. Mediastinal silhouette is not
widened.
IMPRESSION:
Increased opacification of the left upper and left mid lung may be secondary
to pulmonary edema or developing pneumonia.
Radiology Report
INDICATION: Quadriplegia, Staph pneumonia and new transaminitis. Evaluate
left-sided pleural effusion as well as liver given transaminitis.
TECHNIQUE: MDCT axial images were acquired through the torso after the
uneventful administration of 130 ml of Omnipaque. Coronal and sagittal
reformations were provided and reviewed. Oral contrast was administered.
Findings in the chest are reported separately.
DOSE: DLP: 1304.50 mGy-cm
COMPARISON: None.
FINDINGS:
Findings in the chest, including the left lower lobe consolidation and pleural
effusion, are reported separately.
Abdomen: Study is limited by bowel motion artifact in the anterior abdomen.
The liver enhances homogeneously without focal lesions. There is a small
amount of fluid within the gallbladder fossa in the setting of trace abdominal
ascites, otherwise, the gallbladder is normal. There is no intra or
extrahepatic biliary ductal dilation. The spleen, pancreas and adrenal glands
are unremarkable. The kidneys enhance symmetrically and excrete contrast
without hydronephrosis. Bilateral renal hypodensities are too small to
characterize but are presumably simple cysts.
An enteric tube courses into the fundus of the stomach. Evaluation of the
bowel is again limited by motion artifact. There is no bowel wall thickening
or obstruction. There is no free air. There is no retroperitoneal or
mesenteric lymphadenopathy.
The portal vein, splenic vein and superior mesenteric vein are patent. An
infrarenal IVC filter is noted. The aorta is normal caliber. There is a small
focal dissection of the aorta, extending from the level of the right renal
artery to the right iliac vein. There are no findings to suggest end organ
ischemia and all major arterial branches are patent.
Pelvis: The bladder is thickened and a Foley catheter is in place. The rectum
is unremarkable. There is a small amount of free pelvic fluid. There is no
inguinal or pelvic sidewall lymphadenopathy.
Bones and soft tissues: The bones are diffusely demineralized, consistent with
disuse. There is an 8 mm sclerotic lesion in the left iliac wing, which is
likely a bone island in the absence of an oncologic history. Severe
degenerative changes of both hips are noted with near bone-on-bone
articulation.
IMPRESSION:
1. Normal appearing liver.
2. Small, focal dissection in the abdominal aorta, extending from below the
right renal artery to the right common iliac artery. No evidence of end organ
ischemia.
3. Thickened bladder. While this may represent a neurogenic bladder,
correlation with urinalysis is recommended to exclude acute on chronic
cystitis.
4. Trace amount of ascites, non drainable.
5. Findings in the chest reported separately.
NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___
telephone on ___ at 5:25 ___, 15 minutes after discovery of the findings.
Radiology Report
EXAMINATION: CT CHEST W/CONTRAST
INDICATION: Quadriplegic, known Staph pneumonia, and new transaminitis.
Evaluate pneumonia and pleural effusions.
TECHNIQUE: Multidetector helical scanning of the chest was coordinated with
intravenous infusion of nonionic iodinated contrast agent and reconstructed as
contiguous 5- and 1.25-mm thick axial, 2.5-mm thick coronal and parasagittal,
and 8 x 8 mm MIPs axial images.
DOSE: Please see the abdominal CT report for the total DLP value.
COMPARISON: Multiple chest radiographs, dating to ___.
FINDINGS:
The thyroid gland is enlarged. No discrete nodules identified. An
irregularity in the skin along the anterior neck may be from a prior
tracheostomy. There is no discrete fluid collection or stranding in the
subcutaneous tissues. There is no axillary lymphadenopathy. There are numerous
enlarged mediastinal lymph nodes measuring up to 15 mm. Additionally, there is
one enlarged left hilar lymph node measuring 13 mm (2, 28). There is no right
hilar lymphadenopathy.
The heart is normal in size. There is no pericardial effusion. The thoracic
aorta is normal in caliber without significant atherosclerotic calcifications.
The main pulmonary arteries are enlarged for patient of this age, suggesting
pulmonary hypertension.
An endotracheal tube is in satisfactory position within the mid trachea. The
mainstem bronchi are patent. Mucus plugging and bronchial wall thickening is
noted throughout the segmental and subsegmental bronchi, likely related to the
underlying infection.
Motion significantly limits evaluation of the bases. Within the limitations,
there is a dense low attenuation consolidation filling the majority of the
left lower lobe with some associated volume loss. There are air bronchograms.
This is most consistent with a pneumonia.
Additionally, there are other opacities throughout all lobes of the long. For
example, in the right upper lobe there is a rounded opacity with a small
central cavitation (4, 43). Additionally there are ___ and
ground-glass opacities with associated significant bronchial wall thickening.
In the right middle and lower lobes, there are similar ___ opacities
and macronodular opacities. In the left upper lobe there are innumerable
nodular opacities which are coalescing into a larger opacity. All these
opacities are in keeping with a history of staph pneumonia, and likely
represent the infection at different stages of maturity.
There is a small left pleural effusion. No right pleural effusion is
identified. There is no pneumothorax.
There are no concerning lytic or sclerotic osseous lesions. A few mild
compression deformities and moderate degenerative changes in the upper
thoracic spine are likely chronic. Incidentally noted is osseous bridging
between a few anterior left ribs (8, 69 and 67) which may be posttraumatic
Please see the abdominal CT report for complete subdiaphragmatic details.
IMPRESSION:
1. Bilateral pulmonary opacities, some of which are consolidative, some of
which are ground-glass, and some of which are ___, are in keeping with
the history of a Staph pneumonia. The different opacities likely represent the
infectious process at different levels of maturity. Of note, one opacity at
the right apex has a small central cavitation.
2. Mediastinal and left hilar lymphadenopathy. This is likely reactive, though
a repeat chest CT is recommended after treatment to ensure resolution of both
the opacities and this lymphadenopathy.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man intubated with pneumonia // Interval change?
IMPRESSION:
As compared to ___ radiograph, diffuse am, heterogeneous
bilateral pulmonary opacities are mostly similar except for worsening in the
right lower lung. Poorly defined nodular opacities are present with apparent
cavitation. Findings are consistent with multifocal infection. In the setting
of cavitation, septic emboli and granulomatous infection should be considered.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with mrsa pneumonia, recently extubaed, now with
increased work of breathing, tachypnea, concern for pulmonary edeama // pulm
edema, other cause for tachypnea pulm edema, other cause for tachypnea
IMPRESSION:
In comparison with the and nasogastric tubes have study of ___, the
endotracheal been removed. Diffuse bilateral pulmonary opacifications are
essentially unchanged. The poorly defined nodular opacities with apparent
cavitation suggests the possibility of septic emboli or a granulomatous
infection.
Radiology Report
EXAMINATION: CHEST PORT. LINE PLACEMENT
INDICATION: ___ year old man with quadrapelegia, now s/p cardiac arrest with
brief cpr, and reintubated // og tube position, ETT position, any trauma from
cpr Contact name: ___: ___ og tube position, ETT position,
any trauma from cpr
IMPRESSION:
In comparison with the earlier study of this date, there is an placement of an
endotracheal tube with its tip approximately 4.5 cm above the carina.
Nasogastric tube extends at least to the upper stomach, though the side port
appears to be above the esophagogastric junction. Diffuse bilateral pulmonary
opacifications persist.
Radiology Report
EXAMINATION: CR -ABDOMEN (SUPINE ONLY)
INDICATION: ___ year old man with quadriplegia, on fentanyl for sedation,
without bowel movements for days. Please assess for stool burden.
TECHNIQUE: Single supine radiograph of the abdomen.
COMPARISON: CT abdomen pelvis from ___.
FINDINGS:
Air is present in nondilated loops of small and large bowel. No evidence of
obstruction. Moderate fecal loading is present in the left colon. An NG tube
and its side-hole pass just below the diaphragm. IVC filter is present just to
the right of the L3-L4 interspace.
IMPRESSION:
Moderate fecal loading without evidence of obstruction.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man without appropriate increase in hemoglobin after
transfusion, concern for TRALI // Please evaluate for change since this
morning's xray Please evaluate for change since this morning's xray
COMPARISON: Chest radiographs ___ through ___ at 11:57 a.m.
IMPRESSION:
Generalized improvement in background lung density concurrent with mild
decrease in heart size suggests improvement in the component of pulmonary
edema, but considerable abnormality remains, particular bibasilar
consolidation due to infection or hemorrhage. Left pleural effusion is
probably moderate in size, unchanged. There is no pneumothorax.
ET tube is in standard placement, transesophageal drainage tube passes into
the stomach and out of view. Left PIC line ends in the mid SVC.
Radiology Report
EXAMINATION: CTA TORSO
INDICATION: ___ year old man with continued fevers, anemia, and recent cardiac
arrest. CT scan on ___ with focal dissection in the abdominal aorta,
extending from below the right renal artery to the right common iliac artery.
// Evaluate prior dissection, assess for extension or worsening
TECHNIQUE: Spiral aquisition was performed during single phase after
administration of IV contrast. Multiplanar reformats were created.
DOSE: 562 mGy*cm
COMPARISON: CT ___
FINDINGS:
Study is limited by patient motion artifact.
No significant atherosclerosis of normal caliber thoracic aorta. Widely patent
great vessel ostia. No thoracic aortic dissection. Again demonstrated is a
focal right lateral dissection of normal caliber abdominal aorta extending
from just caudal to the right renal artery to the right common iliac artery
ostium, unchanged from prior. No pseudoaneurysm formation. Aortic branches are
widely patent. Normal appearance of the iliac arteries.
Enteric tube likely terminates within the gastric body allowing for motion
artifact. A moderate left subpulmonic effusion is demonstrated, new since
prior. Atelectasis of the left more than right lung bases. Images of the
included chest demonstrate scattered nodular of the solid and ground-glass
opacities, many centrilobular in distribution. Multiple more confluent
opacities now involve the right middle and lower lobes compared to prior
study. No pneumothorax.
Small amount of secretions within the esophagus. Left PICC terminates in the
cephalad SVC. No pericardial effusion. Mediastinal adenopathy is again noted,
largest 1.1 cm right peritracheal.
Motion compromised images of the liver, gallbladder, spleen and adrenals are
unremarkable. Pancreas is grossly unremarkable. No biliary dilatation.
Malrotated right kidney. No hydronephrosis. Subcentimeter hypodensities are
noted, similar to prior, too small to characterize, likely cysts.
Decompressed stomach. Contrast within the rectum and distal colon. No small
bowel dilatation.
Infrarenal IVC filter. Mild generalized stranding of the abdominal mesenteries
noted, possibly artifactual, nonspecific finding. Mild prominence of
retroperitoneal nodes, largest 1.2 cm.
Foley catheter within markedly thick-walled bladder. Trace free pelvic fluid.
Marked bony demineralization with degenerative changes of bilateral hip
joints. Degenerative changes of the posterior elements of the spine. Re-
demonstrated sclerotic focus within the left iliac bone, probable bone island.
IMPRESSION:
-Unchanged appearance of focal dissection extending from below the right renal
artery to the right common iliac arterial ostium.
-More confluent solid/ground-glass opacification of the right middle and lower
lobes compared to prior study. Numerous solid/ground-glass pulmonary nodules
are again demonstrated within the visualized lungs, consistent with history of
pneumonia. New moderate left subpulmonic effusion.
-Mediastinal adenopathy, likely reactive.
-Marked bladder wall thickening, possibly representing cystitis. Mild
prominence of retroperitoneal nodes, possibly reactive.
- Other findings as detailed above.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with ETT, Staph PNA // ETT positioning, interval
change consolidations ETT positioning, interval change consolidations
COMPARISON: Chest radiographs ___ through ___.
IMPRESSION:
Severe multi focal pneumonia has not improved. Small to moderate left pleural
effusion is stable. Heart size is normal. ET tube and left PIC line are in
standard placements. Nasogastric tube ends in the upper stomach the would
need to be advanced 8 cm to move all the side ports beyond the GE junction.
No pneumothorax.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with pneumonia, intubated // Any interval change
in pna?
TECHNIQUE: Single frontal view of the chest
COMPARISON: ___
IMPRESSION:
Bilateral diffuse consolidations / multifocal pneumonia, larger in the left
lower hemi thorax have worsened.
ET tube is in standard position. Right PICC tip is in the mid to lower SVC. NG
tube tip is in the stomach but the side port is probably at the EG junction
and could be advanced for more standard position. There is no evident
pneumothorax. Small left effusion is unchanged. Patient has known mediastinal
lymphadenopathy. Cardiac size is normal
Radiology Report
EXAMINATION: CHEST PORT. LINE PLACEMENT
INDICATION: ___ year old man with new picc // 41cm right picc. ___ iv
___ Contact name: ___: ___ right picc. ___ iv
___
IMPRESSION:
IN COMPARISON WITH THE STUDY OF ___, THE LEFT PICC LINE HAS BEEN REMOVED
AND REPLACED WITH A A RIGHT PICC LINE THAT EXTENDS TO THE MID PORTION OF THE
SVC. THE OPACIFICATION AT THE BASES HAS DECREASED ESPECIALLY ON THE RIGHT. .
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with ETT, PNA // ETT position, interval change
in consolidations ETT position, interval change in consolidations
IMPRESSION:
In comparison with the study of ___, there has been some decrease in the
diffuse bilateral opacification is, clinically consistent with pneumonia. Some
degree of .vascular congestion could well be present. Little change in the
monitoring and support devices
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with ETT increased O2 requirement // interval
change in consolidations
TECHNIQUE: CHEST (PORTABLE AP)
COMPARISON: ___
IMPRESSION:
ET tube tip is 5.4 cm above the carinal. NG tube tip is in the stomach.
Cardiomediastinal silhouette is stable. Widespread parenchymal opacities are
demonstrated.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with ETT new fever // PNA progression PNA
progression
TECHNIQUE: Portable semi erect frontal chest radiograph.
COMPARISON: Frontal chest radiograph ___. Chest CT ___.
FINDINGS:
Endotracheal tube tip terminates 4.6 cm cephalad to the carinal. Nasogastric
tube extends below the diaphragm, however the side port projects at the level
of the gastroesophageal junction. Right PICC tip terminates in the low
superior vena cava.
Medial left lower lobe consolidation with air bronchograms is unchanged likely
representing atelectasis. Patchy right basilar airspace opacities are
unchanged. Mild pulmonary vasculature encroachment is unchanged.
IMPRESSION:
1. Persistent left lower lobe atelectasis.
2. Orogastric tube with side hole projecting at the gastroesophageal junction.
Recommend advancement 5 cm.
3. Unchanged mild pulmonary edema.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with ETT, PNA // tube position
COMPARISON: ___.
IMPRESSION:
As compared to the previous radiograph, no relevant change is seen. Signs of
overinflation an additional multifocal parenchymal opacities, likely
reflecting a combination of scarring and active infection. Predominant foci of
these changes are seen at the right lung bases, the right mid lung and the
left lung bases. Normal size of the cardiac silhouette. No pulmonary edema.
The position of the endotracheal tube and the nasogastric tube are unchanged.
The nasogastric tube could be advanced by approximately 5 cm.
Radiology Report
EXAMINATION: CTA CHEST WANDW/O CANDRECONS, NON-CORONARY
INDICATION: ___ year old man with tachycardia, fever, hypotension, known
pneumonia // PE, abscess formation from MRSA/Klebsiella PNA
TECHNIQUE: MDCT axial images were acquired through the chest following
intravenous administration of 100cc of Omnipaque scanning in the early
arterial phase.
Reformatted coronal, sagittal, thin slice axial images, and oblique maximal
intensity projection images were submitted to PACS and reviewed.
DOSE: DLP: 255 mGy-cm.
COMPARISON: CTA torso dated ___ and CT chest from ___
FINDINGS:
Although this study is not designed for assessment of intra-abdominal
structures, the visualized upper abdomen is unremarkable.
CHEST:
The thyroid is unremarkable and there is no supraclavicular lymph node
enlargement. An ET tube is in appropriate position. Secretions are noted in
the trachea above the ET tube cuff. There is stable mediastinal and hilar
lymphadenopathy. The heart, pericardium and great vessels are within normal
limits. No hiatal hernia is present. An enteric tube is seen with the tip in
the stomach
Evaluation of the pulmonary parenchyma is limited by respiratory motion.
Diffuse bilateral ___ and ground-glass nodules have somewhat improved
compared to the prior study. A cavitated 13 x 21 mm nodule in the right lung
apex is unchanged. Consolidation of the right lower lobe are also unchanged.
The previous seen left pleural effusion has decreased in size, now small.
CTA CHEST:
The aorta and main thoracic vessels are well opacified. The aorta demonstrates
normal caliber throughout thorax without intramural hematoma or dissection.
The pulmonary arteries are opacified to the segmental level. Evaluation of the
subsegmental pulmonary arteries is limited by respiratory motion. There is no
filling defect in the main, right, left, or lobar pulmonary arteries.
OSSEOUS STRUCTURES: No lytic or sclerotic lesion concerning for malignancy is
present. Increased sclerosis of the right fourth and eighth ribs posteriorly
may be related to prior trauma.
IMPRESSION:
1. No evidence of pulmonary embolism to the segmental level. Evaluation of
the subsegmental pulmonary arteries is limited by respiratory motion.
2. Interval improvement in multifocal pneumonia with persistent left lower
lobe consolidation.
3. Unchanged cavitary nodule in the right lung apex.
4. Stable mediastinal lymphadenopathy, likely reactive.
5. ET tube with secretions above the cuff.
NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___ on
the telephone on ___ at 3:22 ___, 5 minutes after discovery of the
findings.
Radiology Report
EXAMINATION: UNILAT UP EXT VEINS US
INDICATION: ___ year old man with new RUE swelling new, PICC right side //
DVT
TECHNIQUE: Grey scale and Doppler evaluation was performed on the right upper
extremity veins.
COMPARISON: None.
FINDINGS:
There is normal flow with respiratory variation in the bilateral subclavian
veins.
The right internal jugular and axillary veins are patent and compressible with
transducer pressure.
The right brachial, basilic, and cephalic veins are patent, compressible with
transducer pressure and show normal color flow and augmentation. The
patient's basilic PICC is visualized.
IMPRESSION:
No evidence of deep vein thrombosis in the right upper extremity.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with quadriplegia chronic respiratory failure
now intubated // interval change interval change
IMPRESSION:
In comparison with the study of ___, the monitoring and support devices
are unchanged. Again there is hyperinflation with multifocal areas of
opacification, especially at the bases, consistent with some combination of
scarring and active infection. There may be some decrease in the basilar
opacifications.
Cardiac silhouette remains within normal limits and there is no evidence of
vascular congestion.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with new trach and OG tube // placement of OG
tube and new trach
TECHNIQUE: Portable AP radiograph of the chest.
COMPARISON: ___.
FINDINGS:
The patient has been extubated, but a tracheostomy tube has been placed. A
nasogastric tube terminates in the stomach, however the side port sits at the
level of the GE junction. A right-sided PICC line terminates in the upper
SVC. A left basilar airspace opacity containing air bronchograms is not
appreciably changed. Scattered reticular nodular opacities, including a
rounded opacity at the right base, are in keeping with the known diagnosis of
multifocal pneumonia.
IMPRESSION:
Persistent multifocal pneumonia with large left lower lobe consolidation and
atelectasis.
Newly placed NG tube terminates in stomach, but its side-port sits at the GE
junction. Advancement by at least 3-4 cm is advised.
Radiology Report
INDICATION: ___ year old man with sudden SOB // ? mucous plug/flash edema
EXAMINATION: CHEST (PORTABLE AP)
TECHNIQUE: Portable Chest radiograph, frontal view
COMPARISON: Chest radiograph ___
FINDINGS:
Right PICC terminates at and mid SVC. Tracheostomy tube is in appropriate
position. Transesophageal tube courses below the diaphragm and out of view.
There are wires and screws projecting over the cervical spine. Reticulonodular
interstitial pattern and left lower lobe consolidation is consistent with
multifocal pneumonia. There is no increased pulmonary edema.
IMPRESSION:
No significant interval change. Persistent reticulonodular interstitial
pattern and left lower lobe consolidation consistent with multifocal
pneumonia.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with trach // change in opacity?
TECHNIQUE: CHEST (PORTABLE AP)
COMPARISON: ___
IMPRESSION:
NG tube tip is in the stomach. Progression of left lower lobe. Atelectasis is
demonstrated. A endotracheal tube tip is approximately 7.7 cm above the
carinal. The apices are unremarkable. Right central venous line tip is at the
level of mid SVC. Right basal opacity most likely represents atelectasis but
attention to this area is recommended. Left basal consolidation is unchanged
Radiology Report
EXAMINATION: VIDEO OROPHARYNGEAL SWALLOW
INDICATION: ___ year old male with past medical history of C4 quadriplegia
with hypoxemic respiratory failure now status post trach, evaluate swallowing.
TECHNIQUE: Oropharyngeal swallowing videofluoroscopy was performed in
conjunction with the speech and swallow division. Multiple consistencies of
barium were administered.
DOSE: Fluoro time: 02:53 min.
COMPARISON: None.
FINDINGS:
Barium passes freely through the oropharynx and esophagus without evidence of
obstruction. There is aspiration of thin, nectar, and honey thick liquids.
IMPRESSION:
Aspiration of thin, nectar, and honey thick liquids.
Please refer to the speech and swallow division note in OMR for full details,
assessment, and recommendations.
Radiology Report
EXAMINATION: CHEST (SINGLE VIEW)
INDICATION: ___ year old man with new trach and sputum // ?pna ?pna
IMPRESSION:
In comparison with the study of ___, the monitoring and support devices
are essentially unchanged. Tracheostomy tube is in place. Bibasilar areas of
opacification are again seen. On the left, there is poor definition of the
hemidiaphragm, suggesting substantial volume loss in the left lower lobe. In
the appropriate clinical setting, superimposed pneumonia would have to be
considered.
Of incidental note is contrast material within the esophagus related to the
very recent oropharyngeal swallow examination.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with new secretions and FiO2 // ?pneumonia
?pneumonia
IMPRESSION:
In comparison with the study of ___, there is little overall change.
Monitoring and support devices remain in place. Bibasilar at areas of
opacification are again seen. On the left, poor definition of the
hemidiaphragms suggests substantial volume loss in the left lower lobe. Again,
however, in the appropriate clinical setting it would be difficult to
definitely exclude superimposed pneumonia.
The contrast material in the the esophagus is not definitely appreciated on
this study.
Radiology Report
INDICATION: ___ year old man with C4 quadriplegia and aspiration with trach
placement. Now needs GJ tube placement // GJ tube placement please
COMPARISON: CT torso ___.
TECHNIQUE: OPERATORS: Dr. ___ resident) and Dr. ___
___ radiology attending) performed the procedure. The attending,
Dr. ___ was present and supervising throughout the procedure. Dr. ___,
___ radiologist, personally supervised the trainee during the key
components of the procedure and reviewed and agreed with the trainee's
findings.
ANESTHESIA: Moderate sedation was provided by administrating divided doses of
75mcg of fentanyl and 1 mg of midazolam throughout the total intra-service
time of 40 min during which the patient's hemodynamic parameters were
continuously monitored by an independent trained radiology nurse. 1% lidocaine
was injected in the skin and subcutaneous tissues overlying the access site.
MEDICATIONS: 1 mg glucagon IV.
CONTRAST: 30 ml of Optiray contrast.
FLUOROSCOPY TIME AND DOSE: 12 min, 40 mGy
PROCEDURE: 1. Placement of a MIC gastrojejunostomy tube.
PROCEDURE DETAILS: Following the discussion of the risks, benefits and
alternatives to the procedure, written informed consent was obtained from the
health care proxy. The patient was then brought to the angiography suite and
placed supine on the exam table. A pre-procedure time-out was performed per
___ protocol. The tube site was prepped and draped in the usual sterile
fashion.
A scout image of the abdomen was obtained. The stomach was insufflated through
the indwelling nasogastric tube. Using a marker, the skin was marked using
palpation to feel the costal margins and the liver edge was marked using
ultrasound.
Under fluoroscopic guidance, 3 T fastener buttons were sequentially deployed
in a triangular position elevating the stomach to the anterior abdominal wall.
Intra-gastric position was confirmed with aspiration of air and injection of
contrast. A 19 gauge needle was introduced under fluoroscopic guidance and
position confirmed using an injection of dilute contrast. The needle
trajectory was directed towards the pylorus. A ___ wire was introduced and
coiled within the stomach. A small skin incision was made along the needle and
the needle was removed.
Kumpe catheter was then introduced over the wire and the ___ was exchanged
for a Glidewire. The Glidewire and a Kumpe cathter was used to advance the
wire into the ___ part of the duodenum. The Glidewire was then exchanged for
an Amplatz wire. The sheath was then removed and, after sequential dilation, a
peel-away sheath was placed over the wire. A 16 ___ MIC gastrojejunostomy
catheter was advanced over the wire into position. The sheath was then peeled
away.
The wire and sheath were removed. The catheter was locked by instilling 7 ml
of dilute contrast into the balloon in the stomach after confirming the
position of the catheter with a contrast injection. The catheter was then
flushed, capped and secured to the skin with 0-silk sutures. Sterile dressings
were applied. The patient tolerated the procedure well and there were
noimmediate complications.
FINDINGS:
1. Successful placement of a 16 ___ MIC gastrojejunostomy tube with its tip
in the proximal jejunum.
IMPRESSION:
Successful placement of a 16 ___ MIC gastrojejunostomy tube with its tip in
the proximal jejunum. The gastric port should not be used for 24 hours.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with respiratory failure // change in left lower
lobe volume change in left lower lobe volume
IMPRESSION:
In comparison with the study of ___, the nasogastric tube is been
removed. Tracheostomy tube and right PICC line remain in good position. The
little change in the appearance of the heart and lungs.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Abnormal sodium level, Dyspnea, Transfer
Diagnosed with PNEUMONIA,ORGANISM UNSPECIFIED
temperature: 97.5
heartrate: 71.0
resprate: 22.0
o2sat: 96.0
sbp: 118.0
dbp: 86.0
level of pain: 0
level of acuity: 2.0 | Mr. ___ is a ___ with PMHx of C4 quadriplegia secondary to
a football accident ___ years ago, Hx of hyponatremia (Na
125-130 ___ ___, ?CAD per chart, multiple UTIs, and other
issues who was transferred from an OSH after presenting with
dypsnea; now with hypoxemic respiratory failure and profound
hyponatremia.
# Hypoxemic respiratory failure:
Patient prsented with hypoxemic respiratory failure felt to be
multifactorial ___ the setting of multifocal pneumonia and mucous
plugging ___ setting of quadriplegia and impaired cough reflex.
Mucous plugging is likely given appearance of a volume loss
lesion without air bronchograms on CXR; also compatible w/
clinical history of increased cough and mucous. Pneumonia also
likely given 21% bands and patchy alveolar opacities on the R.
He was electively intubated on ___ and underwent bronch which
showed extensive mucous. Initially treated with Broad empiric
ABx coverage with azithromycin, pip/tazo, and vancomycin as
below. BAL grew MSSA though so he was switched to unasyn on ___
however sputum culture showed MRSA so patient changed back to
vancomycin. Trial of extubation on ___ was attempted.
Patient developed transient pulmonary edema after loss of PEEP
with extubation. He received 10 mg IV lasix and BIPAP with
improvement of respiratory distress. Patient subsequently
developed bradycardia that resulted ___ asystolic cardiac arrest.
ROSC was achieved without medications within 2 minuts of CPR.
The patient was reintubated on ___ for airway protection.
Trach placed on ___. Patient was maintained on pressure
support at night but remained on trach mask during day.
# Multifocal Pneumonia MRSA and MSSA PNA:
Patient's initial presentation felt to be secondary to viral URI
due to adenovirus noted on initialy sputum study with resulting
MRSA/MSSA and Klebsiellae pneumonia.
Patient with Pneumonia at time of admission that was treated
with broad spectrum antibiotics on ___ with azithromycin,
pip/tazo, and vancomycin. MSSA was initially shown ___ BAL so
unasyn started however subsequent sputum culture showed MRSA and
vancomycin restarted (___). Serial BAL's and sputum
cultures obtained given recurrent fevers ___ patient post-cardiac
arrest. There was concern for aspiration pneumonia and do to
this flagyl and cefepime started for braoder coverage. Sputum
culture from ___ showed Klebsiella susceptible to
ciprofloxacin and as such cefepime and flagyl stopped and
cirprofloxacin started on ___ - ___. ___ addition
given drug rash thought to be associated with vancomyin. As such
vancomycin discontinued on ___ and linezolid started ___ -
___. Total duration of treatment to be determined by ID as
patient continued to have fevers at this point. Placed on
bactrim ___ for bronch/bal with findings of klebsiella
sensitive to bactrim (last dose ___ ___ the setting of
increased secretions.
Patient will require LTACH LOC for vent weaning w/daily MD
intervention. ___ w/continued chest ___, quad cough, standing and
PRN nebs, starting to use MIE
#VAP Klebsiella Pneumonia
Patient noted to have Klebsiella on BAL studies and started on
ciprofloxacin on ___.
#Elevated PTT: Patient noted to have elevated PTT that did not
improve with holding subcutaneous heparin or IV Vitamin K.
Hem/onc consulted who recommended mixing study that showed: On
50:50 mix, aPTT at time zero is 49.4 On 50:50 mix, aPTT at 2
hours is 48 that was considered to be positive. It was felt that
the most likely cause of the positive mixing study was likely a
lupus anti-coagulant ___ the setting of critical illness though
it was not checked. As such, ___ setting of critical illness no
further interventions including anticoagulation were
recommended. Elevated PTT was not thought to be indicative of
increased bleeding risk.
#Cardiac Arrest: Patient subsequently developed bradycardia that
resulted ___ asystolic cardiac arrest. ROSC was achieved without
medications within 2 minuts of CPR. The patient was reintubated
on ___ for airway protection.
# Bradycardia with cardiac arrest: Thought to be secondary to
autonomic dysfunction as well as possible increased vagal tone
with mucous plugging. EP consulted with recommendation for
premedication with atropine for procedures that may stimulate
the vagal nerve. ___ addition patient furthermore had 3 more
episodes of bradycardia requiring atropine. ___ addition patient
had brief episode of asystole on ___ that improved with
atropine. Overall per EP there was no indication for pacemaker
and all vagal nerve stimualating procedures were avoided as
able.
# Rash: Patient developed rash thought to be secondary to viral
exanthem vs drug eruption that changed ___ distribution. CBC with
dif did not show eosinphilia to suggest DRESS and LFT's also
remained stable. Some component of the rash was thought to be
due to viral etiology ___ setting of positive adenovirus at time
of admission. Derm consulted and felt that patient's rash was
likely secondary to zosyn or penicillin both of which had been
stopped and added to patient's allergy list. It was felt that
these rashes could be seen even after stopping the antibiotics
for 2 weeks. Clobetasol 0.05% topical ointment started with
improvement of rash.
#Autonomic Dysreflexia: Patient noted to have autonomic
dysreflexia with labile blood pressures ___ the setting of known
quadraplegia. Midodrine was continued with slight adjustments ___
dosage. Neurology also consulted who recommended sitting patient
up if hypertensive or lying patient down if hypotensive wiht leg
raise. They also suggested avoiding vagally stimulating
maneuvers after giving midodrine that could potentiate
hypertension.
# Hyponatremia: Likely chronic hyponatremia ___ the setting of
quadraplegia (from possibly hypotension-mediated ADh release,
lack of renal innervation, etc) acutely worsened by pulmonary
process (pneumonia/mucus plug) and an excess of free water
intake relative to solute; the only baseline we have is a value
of 125 from ___. Urine Na of 30 did not suggest sodium
avidity, and his urine is isosthenuric. Excretion of
isosthenuric albeit dilute urine with high urine output
suggested that his kidneys may be functioning normally and will
correct. Cerebral salt wasting is unlikely given that this is
more often seen with SDH and other intracranial insults; is less
likely given that patient was not hypovolemic on exam, and no
improvement ___ Na with normal saline at OSH. With
recommendations from renal team, patient was placed on
hypertonic saline and Na returned to baseline on ___ without
further intervention.
#Anemia
Patient noted to have anemia on ___ requiring blood
transfusion. Patient was transfused with some improvement ___
blood counts. Hemolysis labs were unreavealing. Reticulocyte
index low but felt to be this way ___ setting of active infection
and marrow suppression. ___ addition repeat CTA completed to
ensure stable nature of previously noted abdominal aortic
dissection that remained stable and unchanged from prior.
# Hypokalemia: K 2.8 on arrival, likely occurring ___ the setting
of profound natriuresis to correct free water excess. No ECG
abnormalities on admission. Aggressively repleted during
admission and normalized by disdcharge.
# Transaminitis: Unclear etiology, possibly related to
adenovirus noted on BAL. Hepatitis serologies were negative.
EBV and CMV VL were negative. Resolved prior to discharge.
# C4 quadroplegia: secondary to trauma ___ ___. Uses CIC at
home for neurogenic bladder and digital stimulation for stool
removal. He received stool softeners. He also received
scheduled disimpaction. Foley was maintained for urinary
retention and UOP monitoring.
# Hx of UTI: No old microbiology data available, but high
likelihood of colonization and resistant organisms. No positive
urine cultures during this hospitalization.
# Nutrition: noted to have aspiration on video oropharyngeal
swallow. Maintained on tube feeds during hospitalization.
Evaluated by nutrition and because of concern that patient would
be unable to keep up with calorie intake, patient had J tube
placed on ___. Nutrition recommended ENT evaluation of vocal
cords and PES given concern for reduced vocal cord closure which
could increase aspiration risk. ENT evaluated patient with
laryngoscopy and found bilateral vocal fold atrophy and left
vocal fold immobility
with thoughts that dysphagia was secondary to glottic
incompetence rather than CP bar - patient is to follow up one
week after discharge for temporary vocal fold injection to
restore glottic incompetence. Nutrition recommended patient
continue swallow exercises ___ sessions per day, remain NPO, and
perform q4 oral care, especially just prior to swallow
exercises.
TRANSITIONAL ISSUES
===========================
*Please note, patient had frequent issues with mucus plugging
and increased secretions requiring suctioning. He required
frequent bronch/bal during hospitalization. Bronch/bal performed
on ___ had minimal secretions.
MEDICATION & LAB/FOLLOW UP
- At rehab, MIE TID AND PRN
- Monitor eosinophilia, likely ___ medication but can trend
- Consider MIP/MEP to assess neuromuscular weakness
- Nafcillin/piperacillin are now new allergies
- F/u PMR ___ outpatient setting
- Please check magnesium levels q3 days as patient frequently
was noted to have hypomagnesemia
- Please monitor Zenker diverticulum
- Bactrim started on ___ for bronch/bal with findings of
klebsiella sensitive to bactrim ___ the setting of increased
secretions (last dose ___
- patient was noted to have episodes of hypotension while
___. Neurology evaluated patient and determined that this
was likely secondary to autonomic dysfunction. Should he get
hypotensive, please try lifting his legs and this usually
resolves the situation.
-Patient will require LTACH LOC for vent weaning w/daily MD
intervention. Settings of vent at night (pressure support ___,
FiO2 50%)
- patient was noted to have episodes of hypotension while
___.
-please follow up final BAL cultures from ___ and ___
APPOINTMENT FOLLOW UP
- Make appt with Dr. ___ for one week after discharge
because patient would benefit from vocal cord augmentation with
injection of temporary filler as a trial. His clinic number is
___.
- When he is discharged from ___, ask them to call ___
___ to set up an appointment with Dr. ___
___
- Heme onc f/u appointment of lupus anticoagulant ___ the
outpatient setting
IMAGING FOLLOW UP
- Repeat CT ___ ___ weeks to ensure resolution of lymphadenopathy
and consolidations and cavitary lesions and lobar collapse ___
left lower lobe.
- Noted to have right lateral dissection of abdominal aota
extending caudal to right renal artery to the right common
illiac artery ostium that remained stable form admission. Should
be followed up upon discharge to ensure it stays stable
- NOTED to have abdominal aortic dissection. Small and stable. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Left weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a ___ year old woman awakening at 0800 with
left sided weakness. She has a history of a prior stroke (likely
an intraparenchymal hemorrhage from a cavernous malformation in
___ with left sided weakness), CAD, HTN (on three
antihypertensives), HL, and DM2. She was last seen well at 2200
(her bedtime) on ___. She awoke and could not move her left
side well. She did not think her face was asymmetric and did not
have any dysarthria. She did not have any headache. She felt
tired and lethargic but has been able to stay awake. She had a
recent cold with rhinorrhea which she had just recovered from
yesterday. She was brought to ___ where a
___
revealed a right thalamic IPH, and she was subsequently
transferred here. A Nicardipine infusion was started in the ED
for a BP 210/106 at triage which has since kept her SBP in the
120-140 range. She feels that her symptoms have remained overall
unchanged since this morning.
On review of systems, the patient endorses: left sided weakness.
On review of systems, the patient denies the following:
- Neurologic: headache, confusion, difficulty producing speech,
difficulty understanding speech, vision loss, diplopia, vertigo,
dysarthria, dysphagia, sensory loss, gait imbalance.
- Constitutional: fever, rigors, night sweats, unintentional
weight loss.
- Cardiovascular: chest pain, palpitations, lightheadedness.
- Gastrointestinal: nausea, emesis, diarrhea, constipation.
- Genitourinary: dysuria, urinary urgency, urinary incontinence.
- Ear, Nose, Throat: tinnitus, hearing loss, rhinorrhea,
odynophagia.
- Hematologic: bleeding, easy bruising.
- Musculoskeletal: arthralgia, myalgia.
- Psychiatric: anxiety, depression.
- Respiratory: dyspnea, cough, hematemesis.
- Skin: rash, new skin lesions.
Past Medical History:
[] Neurologic - Stroke (uncertain type, but reported history of
intracranial cavernous angioma; ___, episode with )
[] Cardiovascular - CAD, HTN, HL
[] Endocrine - DM2
[] Gastrointestinal - GERD
[] Psychiatric - Depression, Anxiety
Social History:
___
Family History:
Family History: Stroke (mother, unknown type). ___
(mother).
Physical Exam:
Physical Examination:
VS T: 97.6 HR: 80 BP: 210/106 -> ___ RR: 20 SaO2: 98%
2LNC -> RA
- General/Constitutional: Lying in bed comfortably, tired
appearing elderly woman.
- Eyes: Round, regular pupils. No conjunctival icterus, no
injection.
- Ear, Nose, Throat: No oropharyngeal lesions. No external
auditory canal lesions.
- Neck: No meningismus. No carotid, vertebral, or subclavian
bruits appreciated. No lymphadenopathy.
- Musculoskeletal: Range of motion with neck rotation minimally
limited bilaterally. No focal spinal tenderness.
- Skin: No rashes. No concerning lesions appreciated.
- Cardiovascular: Regular rate. Regular rhythm. No murmurs,
rubs,
or gallops appreciated. Normal distal pulses.
- Respiratory: Lungs clear to auscultation bilaterally. No
crackles. No wheezes.
- Gastrointestinal: Soft. Nontender. Nondistended. Obese.
- Psychiatric: Mood congruent with affect, occasionally smiles
appropriately. Intact insight.
Neurologic Examination:
- Mental Status - Awake, drowsy. Oriented to name, ___,
current location; not oriented to day of week or date. Attention
to examiner easily attained and maintained. Abulic and
bradyphrenic. Recalls a coherent history, but with little detail
volunteered initially. Speech is fluent with short sentences.
Follows midline and appendicular commands. Intact repetition.
Intact high frequency and low frequency naming. No paraphasias.
Normal prosody. No dysarthria. No ideomotor apraxia. No
hemineglect.
- Cranial Nerves - [II] PERRL 3->1 brisk. VF full to number
counting. Unable to perform fundoscopy due to small pupils.
[III,
IV, VI] EOMI, no nystagmus. [V] V1-V3 without deficits to light
touch bilaterally. [VII] No facial movement asymmetry. [VIII]
Hearing intact to finger rub bilaterally. [IX, X] Palate
elevation symmetric. [XI] SCM/Trapezius strength ___ bilaterally
to confrontation, but incomplete elevation of the left shoulder.
[XII] Tongue midline.
- Motor - Normal bulk and tone. Left arm pronation and drift,
but
not to the bed. No tremor, asterixis, or myoclonus.
[ Direct Confrontational Strength Testing ]
Arm
Deltoids [C5] [R 4 pain limited] [L 3]
Biceps [C5] [R 50] [L 4+]
Triceps [C6/7] [R 5-] [L 4-]
Extensor Carpi Radialis [C6] [R 5] [L 4]
Extensor Digitorum [C7] [R 5] [L 5-]
Flexor Digitorum [C8] [R 5] [L 5]
Leg
Iliopsoas [L1/2] [R 5] [L 4-]
Quadriceps [L3/4] [R 5] [L 5]
Hamstrings [L5/S1] [R 5] [L 4]
Tibialis Anterior [L4] [R 5-] [L 4]
Gastrocnemius [S1] [R 5] [L 5]
- Sensory - No deficits to cold temperature or proprioception
bilaterally. No extinction to DSS.
- Reflexes
=[Bic] [Tri] [___] [Quad] [Gastroc]
L 3 3 3 2 1
R 3 3 3 0 1
Plantar response flexor on the right, extensor on the left.
___ signs present bilaterally. Pectoralis reflexes present
bilaterally. Grip and grasp reflexes present bilaterally.
- Coordination - No dysmetria with finger to nose testing on the
right. Intact cadence and accuracy with rapid alternating
movements (finger tap) on the right. Too weak to elevate left
arm.
- Gait - Unable to assess at the time of examination.
Discharge:
Physical Examination:
NAD
RRR
NTND
Normal WOB
Ext WWP
Neurologic Examination:
- Mental Status - Awake, Oriented to name, hospital, ___.
Attention
to examiner easily attained and maintained. Follows midline and
appendicular commands. Intact repetition.
- Cranial Nerves - [II] PERRL 3->1 brisk. VF full to number
counting. Unable to perform fundoscopy due to small pupils.
[III,
IV, VI] EOMI, no nystagmus. [V] V1-V3 without deficits to light
touch bilaterally. [VII] No facial movement asymmetry. [VIII]
Hearing intact to finger rub bilaterally. [IX, X] Palate
elevation symmetric. [XI] SCM/Trapezius strength ___ bilaterally
to confrontation, but incomplete elevation of the left shoulder.
[XII] Tongue midline.
- Motor - Normal bulk and tone. Left arm pronation and drift,
but
not to the bed. No tremor, asterixis, or myoclonus.
Limited due to patient cooperation
Arm
Deltoids [C5] [R 5] [L 3]
Biceps [C5] [R 5] [L 4+]
Triceps [C6/7] [R 5-] [L 4-]
Extensor Carpi Radialis [C6] [R 5] [L 4]
Extensor Digitorum [C7] [R 5] [L 5-]
Flexor Digitorum [C8] [R 5] [L 5]
Leg
Iliopsoas [L1/2] [R 5] [L 4-]
Quadriceps [L3/4] [R 5] [L 5]
Hamstrings [L5/S1] [R 5] [L 4]
Tibialis Anterior [L4] [R 5-] [L 4]
Gastrocnemius [S1] [R 5] [L 5]
- Sensory - No deficits to cold temperature or proprioception
bilaterally. No extinction to DSS.
- Coordination - No dysmetria with finger to nose testing on the
right. Intact cadence and accuracy with rapid alternating
movements (finger tap) on the right. Too weak to elevate left
arm.
Pertinent Results:
___ 01:15PM LIPASE-24
___ 01:15PM cTropnT-<0.01
___ 01:15PM CALCIUM-9.2 PHOSPHATE-3.4 MAGNESIUM-1.9
___ 01:15PM WBC-9.2 RBC-4.89 HGB-13.5 HCT-43.4 MCV-89
MCH-27.5 MCHC-31.0 RDW-14.7
___ 01:15PM NEUTS-79.3* LYMPHS-14.7* MONOS-4.7 EOS-0.8
BASOS-0.6
___ 01:15PM PLT COUNT-313
___ 01:15PM ___ PTT-31.8 ___
___ 05:45AM BLOOD WBC-8.7 RBC-3.98* Hgb-11.0* Hct-35.1*
MCV-88 MCH-27.7 MCHC-31.4 RDW-15.0 Plt ___
___ 06:00AM BLOOD WBC-10.2 RBC-4.44 Hgb-12.1 Hct-39.0
MCV-88 MCH-27.2 MCHC-30.9* RDW-15.1 Plt ___
___ 05:45AM BLOOD ___
___ 01:50AM BLOOD ___ PTT-29.0 ___
___ 01:15PM BLOOD ___ PTT-31.8 ___
___ 05:45AM BLOOD Glucose-127* UreaN-26* Creat-0.8 Na-137
K-3.8 Cl-108 HCO3-23 AnGap-10
___ 06:00AM BLOOD Glucose-135* UreaN-20 Creat-0.8 Na-139
K-4.1 Cl-109* HCO3-22 AnGap-12
___ 02:49AM BLOOD Glucose-142* UreaN-17 Creat-0.9 Na-139
K-4.3 Cl-106 HCO3-18* AnGap-19
___ 05:45AM BLOOD Calcium-8.7 Phos-3.4 Mg-2.0
___ 06:00AM BLOOD Calcium-8.7 Phos-3.0 Mg-2.1
MRI brain with and without contrast:
IMPRESSION:
1. Organizing hematoma with vasogenic edema centered in the
right thalamus,
likely hypertensive in origin. Given the presence of blood
products at the
site, evaluation for another underlying substrate, such as
cavernous angioma,
is quite limited.
2. Patchy marginal enhancement at this site, above, likely
reflecting an
organizing hematoma.
3. Numerous microbleeds in the usual target sites for
hypertension; however,
there are also atypical superficial foci, as well as evidence of
superficial
siderosis involving the posterior aspect of the right temporal
lobe, raising
the possibility of leptomeningeal involvement from underlying
cerebral amyloid
angiopathy.
4. No space-occupying lesion or pathologic enhancement
elsewhere in the
brain.
5. Relatively mild global atrophy, with no finding to suggest
hydrocephalus.
CT brain without contrast on ___:
The intraparenchymal hemorrhage centered in the right basal
ganglia is stable
in size, measuring 2.1 x 1.3 cm (3:18). There is no new
hemorrhage. There is
no shift of normally midline structures. The ventricles and
sulci are normal
in size configuration. The basal cisterns are patent and the
gray-white matter
differentiation is preserved. Periventricular white matter
hypodensities are
consistent with chronic small vessel ischemic disease. The
visualized
paranasal sinuses, mastoid air cells, and middle ear cavities
are clear.
IMPRESSION:
Stable right basal ganglia intraparenchymal hemorrhage.
Medications on Admission:
Glipizide ER 2.5 mg
daily, Metoprolol tartrate 100 mg BID, Fluoxetine 40 mg daily,
Lisinopril 40 mg daily, Clonidine 0.3 mg HS, Simvastatin 20 mg
daily, Aspirin 81 mg daily, Trazodone 25 mg HS, Ibuprofen 800 mg
prn
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain or fever
2. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
3. Calcium Carbonate 500 mg PO QID:PRN heart burn
4. Clonidine Patch 0.3 mg/24 hr 1 PTCH TD QSAT
5. Fluoxetine 40 mg PO DAILY
6. Glucose Gel 15 g PO PRN hypoglycemia protocol
7. Heparin 5000 UNIT SC TID
8. HydrALAzine 10 mg IV Q6H:PRN SBP > 140
9. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using REG Insulin
10. Lisinopril 40 mg PO DAILY
11. Metoprolol Tartrate 100 mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Thalamic stroke
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
HISTORY: History of intraparenchymal hemorrhage, weakness, evaluate for
intraparenchymal bleed.
COMPARISON: Reference CT from ___.
TECHNIQUE: Contiguous axial MDCT images were obtained through the brain
without the use of intravenous contrast material. Reformatted coronal and
sagittal and thin section bone algorithm reconstructed images were obtained.
Due to motion, multiple scans were attempted.
FINDINGS: There continues to be a right thalamic hemorrhage with associated
edema, relatively similar in size compared to the CT from ___ at
10:43 a.m. No new acute hemorrhage, mass effect or vascular territorial
infarction is noted. There is preservation of normal gray-white matter
differentiation. Periventricular and subcortical white matter hyperdensities
are likely sequela of chronic small vessel ischemic disease. The ventricles
and sulci are appropriate in size and configuration for age. vExtensive
vascular calcifications are seen with ectatic arteries. No fractures are
identified. The visualized paranasal sinuses and mastoid air cells are clear.
The globes are intact.
IMPRESSION: Stable right thalamic hemorrhage with associated edema, similar
in size compared to CT from ___ at 10:43 a.m.
Radiology Report
MR EXAMINATION OF THE BRAIN WITHOUT AND WITH CONTRAST, ___
HISTORY: ___ female with right intraparenchymal hemorrhage, history
of cavernous hemangioma; evaluate extent of IPH, hydrocephalus and compression
of the third ventricle.
TECHNIQUE: Routine ___ enhanced MR examination, comprising T1-weighted
axial SE and sagittal MP-RAGE sequences, the latter with axial and coronal
reformations.
FINDINGS: The study is compared with the NECT dated ___. Again
demonstrated is the parenchymal hemorrhage centered in the right thalamus,
demonstrating predominant T1-iso and T2-hyperintensity with "substantial
blooming" susceptibility artifact on the GRE sequence, representing
deoxyhemoglobin related to acute hemorrhage. There is a zone of vasogenic
edema with some mass effect on adjacent structures, but no subfalcine or more
central herniation. While there is no other acute hemorrhage, there is a
superficial "blooming" artifact involving the posterior right temporal cortex,
superficially (___), which may represent superficial siderosis. There
are also numerous smaller foci of susceptibility artifact scattered through
both cerebral hemispheres, including three such foci in the contralateral
thalamus, as well as in the brainstem and both cerebellar hemispheres, without
associated vasogenic edema. These deeper microbleeds are strongly suggestive
of a hypertensive etiology, particularly given the current thalamic
hemorrhage, as well as the moderate sequela of chronic small vessel ischemic
disease. However, the more superficial foci of susceptibility artifact, not
explained by calcification on the CT, as well as the apparent focal
superficial siderosis, are more strongly suggestive of underlying cerebral
amyloid angiopathy.
The remainder of the examination demonstrates relatively mild global atrophy,
with no finding to suggest hydrocephalus. Allowing for the extensive
susceptibility artifact, above, there is no focus of slow diffusion to suggest
acute ischemia, and the principal intracranial vascular flow voids, including
those of the dural venous sinuses, are preserved and these structures enhance
normally. There is wispy marginal enhancement about the hematoma,
particularly its right posterolateral aspect (14:14, 101:78). Otherwise,
there is no pathologic parenchymal, leptomeningeal or dural focus of
enhancement.
IMPRESSION:
1. Organizing hematoma with vasogenic edema centered in the right thalamus,
likely hypertensive in origin. Given the presence of blood products at the
site, evaluation for another underlying substrate, such as cavernous angioma,
is quite limited.
2. Patchy marginal enhancement at this site, above, likely reflecting an
organizing hematoma.
3. Numerous microbleeds in the usual target sites for hypertension; however,
there are also atypical superficial foci, as well as evidence of superficial
siderosis involving the posterior aspect of the right temporal lobe, raising
the possibility of leptomeningeal involvement from underlying cerebral amyloid
angiopathy.
4. No space-occupying lesion or pathologic enhancement elsewhere in the
brain.
5. Relatively mild global atrophy, with no finding to suggest hydrocephalus.
6. Likely dolichoectasia of the intracranial vessels.
Radiology Report
STUDY: Pre-MRI orbits ___.
CLINICAL HISTORY: ___ woman with right thalamic ICH and ocular
implant.
FINDINGS: Two views of the patient looking up and down demonstrate no
radiopaque densities projecting over the orbits. The paranasal sinuses are
within normal limits. Based on these images, there are no contraindications
to MRI imaging.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ year old woman with IPH // hemorrhage size. Evaluation for
interval change.
TECHNIQUE: Routine unenhanced head CT was performed and viewed in brain,
intermediate and bone windows. Coronal and sagittal reformats were also
performed.
DOSE: DLP: 829 mGy-cm
CTDI: 52.66 mGy
COMPARISON: ___ at 15:55.
FINDINGS:
The intraparenchymal hemorrhage centered in the right basal ganglia is stable
in size, measuring 2.1 x 1.3 cm (3:18). There is no new hemorrhage. There is
no shift of normally midline structures. The ventricles and sulci are normal
in size configuration. The basal cisterns are patent and the gray-white matter
differentiation is preserved. Periventricular white matter hypodensities are
consistent with chronic small vessel ischemic disease. The visualized
paranasal sinuses, mastoid air cells, and middle ear cavities are clear.
IMPRESSION:
Stable right basal ganglia intraparenchymal hemorrhage.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: HEAD BLEED
Diagnosed with INTRACEREBRAL HEMORRHAGE
temperature: 97.6
heartrate: 80.0
resprate: 20.0
o2sat: 98.0
sbp: 210.0
dbp: 106.0
level of pain: 0
level of acuity: 2.0 | Ms ___ was hospitalized due to symptoms of left sided
weakness ultimatley found to be a bleed in her brain. We believe
that this is due to her high blood pressure and abnormal vessels
in her brain called a cavernous malformation. She also has right
posterior temporal lobe superficial siderosis that raises
concern for prior SAH due to amyloid angiopathy - however, the
location of the current bleed is unlikely to have been caused by
amyloid angiopathy. She was initially in the ICU but after
several brain images, the bleed was stable. We restarted home
medications for blood pressure control, with goal of BP < 160
but this can be saftely lowered to normotensive over the next
week. Physical therapy recommended she go to ___ rehab. We
have discussed with her PCP regarding ASA, he has no objections
to holding her ASA which she had been taking prior to her
hospitalization given her history of CAD. We will plan on
holding off on ASA in the interim period. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Cough/Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo male with history of CKD, HTN and CHF on 60 mg Torsemide
daily presenting with cough, SOB, and orthopnea over the last
month worsening over the last few days. Notes he has been
sleeping up in a chair over the last 2 days due to orthopnea.
Also noted pink streaked sputum with cough though no fever or
chills. He denies any chest pain. Lower extremity edema improved
from his baseline per his report. The patient notes he weighs
himself almost daily and that his weight has gone up a few
pounds over the last week. He believes his dry weight is about
205 lbs. He notes he misses his torsemide dose regularly about 3
times per week. He Does not know the names of all of his
medications notes that are taken from a pill box set up for him
and takes a total of 7 pills per day.
He denies any fever, chills, abdominal pain, nausea, vomiting,
chest pain, palpitations, or dysuria.
In the ED initial vitals were:
Temp 98.3 HR 95 BP 164/109 RR 18 SpO2 98% RA
EKG: Sinus rhythm. Biatrial enlargement. Right bundle-branch
block unchanged from prior.
Labs/studies notable for:
WBC 9.2, Hg 10.6, Hct 33.0, platelets 206. Na 138, K 3.1, Cl
98, bicarb 26, BUN 40, Cr 5.3, glucose 173. BNP 4912 (baseline
6721-17, 108), trop 0.10 (baseline 0.10). INR 1.0
CXR showed: FINDINGS:
Compared to the previous examination of ___. The
heart appears smaller enlarged and there is increased
generalized haziness of the lung fields indicating interstitial
edema. No focal pneumonia. No pleural effusions.
Conclusion: Enlarged heart with CHF.
Patient was given: 20 mg PO Torsemide
Vitals on transfer:
Temp 98.2, HR 88, BP 174/110, RR 17, 97% RA
On the floor, the patient notes he feels well. He continues to
have intermittent cough and orthopnea but is resting comfortably
currently.
ROS:
On review of systems, denies any prior history of stroke, TIA,
deep venous thrombosis, pulmonary embolism, bleeding at the time
of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. Denies recent fevers, chills or rigors.
Denies exertional buttock or calf pain. All of the other review
of systems were negative. Cardiac review of systems is notable
for absence of chest pain, palpitations, syncope or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: Hypertension
2. CARDIAC HISTORY: Systolic Heart failure: EF 35%, NYHA class
2
3. OTHER PAST MEDICAL HISTORY:
Stage IV CKD, HTN, Prior h/o DM.
Social History:
___
Family History:
HTN
DMII
CAD
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VS: T= 98.2 BP= 115/105 HR= 88 RR= 18 O2 sat= 8=98% RA weight
98.2 kg
GENERAL: In NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple with JVP of 5 cm above sternal angle HOB at 45
degrees.
CARDIAC: Normal S1, S2. No murmurs/rubs/gallops. No thrills,
lifts.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Bilateral crackles
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: 1+ edema to mid-shins bilaterally
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: Distal pulses palpable and symmetric
DISCHARGE PHYSICAL EXAM:
========================
VS: T=97.7 Tm = 98.4 BP 140/95 (130-155/79-105) HR85 (78-88) R18
94% RA
Weight 97.9
GENERAL: NAD. Mood, affect appropriate
HEENT: PERRL. Sclera anicteric. MMM.
NECK: JVP of 5cm above sternal angle HOB at 45 degrees.
CARDIAC: RRR. No murmurs rubs or gallops. S4.
LUNGS: Mild bibasilar crackles.
ABDOMEN: +BS, nontender to palpation.
EXTREMITIES: No pedal edema. Warm. DP pulses palpable and
symmetric. No stasis changes.
Pertinent Results:
ADMISSION LABS:
===============
___ 03:52PM BLOOD WBC-9.2# RBC-3.40* Hgb-10.6*# Hct-33.0*
MCV-97 MCH-31.2 MCHC-32.1 RDW-14.5 RDWSD-51.2* Plt ___
___ 03:52PM BLOOD Neuts-78.7* Lymphs-11.0* Monos-6.2
Eos-2.9 Baso-0.4 Im ___ AbsNeut-7.25* AbsLymp-1.01*
AbsMono-0.57 AbsEos-0.27 AbsBaso-0.04
___ 03:52PM BLOOD ___ PTT-29.5 ___
___ 03:52PM BLOOD Plt ___
___ 03:52PM BLOOD Glucose-173* UreaN-40* Creat-5.3* Na-138
K-3.1* Cl-98 HCO3-26 AnGap-17
___ 03:52PM BLOOD CK(CPK)-546*
___ 03:52PM BLOOD CK-MB-5 proBNP-4912*
___ 03:52PM BLOOD cTropnT-0.10*
DISCHARGE LABS:
===============
___ 07:49AM BLOOD WBC-7.2 RBC-3.27* Hgb-9.9* Hct-31.6*
MCV-97 MCH-30.3 MCHC-31.3* RDW-14.8 RDWSD-51.9* Plt ___
___ 07:49AM BLOOD Plt ___
___ 02:12PM BLOOD Glucose-186* UreaN-47* Creat-5.2* Na-141
K-3.8 Cl-103 HCO3-23 AnGap-19
___ 02:12PM BLOOD Calcium-7.4* Phos-4.0 Mg-2.2
___ 03:59AM BLOOD calTIBC-252* Ferritn-195 TRF-194*
IMAGING:
========
___ TTE:
The left atrium is mildly dilated. The right atrium is
moderately dilated. The estimated right atrial pressure is ___
mmHg. There is moderate symmetric left ventricular hypertrophy.
The left ventricular cavity size is normal. Overall left
ventricular systolic function is low normal (LVEF 50-55%)
secondary to mild global hypokinesis. Right ventricular chamber
size is normal with mild global free wall hypokinesis. The
ascending aorta is mildly dilated. The aortic valve leaflets (3)
appear structurally normal with good leaflet excursion and no
aortic stenosis or aortic regurgitation. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Mild (1+) mitral regurgitation is seen. There is
mild-moderate pulmonary artery systolic hypertension. There is
no pericardial effusion.
Compared with the prior study (images reviewed) of ___,
mild global right ventricular systolic dysfunction is now
appreciated. Other findings are similar.
___ CXR:
Compared to the previous examination of ___. The
heart appears smaller enlarged and there is increased
generalized haziness of the lung fields indicating interstitial
edema. No focal pneumonia. No pleural effusions.
Conclusion: Enlarged heart with CHF.
MICROBIOLOGY:
___ Sputum Culture:
GRAM STAIN (Final ___:
<10 PMNs and >10 epithelial cells/100X field.
Gram stain indicates extensive contamination with upper
respiratory
secretions. Bacterial culture results are invalid.
PLEASE SUBMIT ANOTHER SPECIMEN.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Tamsulosin 0.8 mg PO QHS
3. Amlodipine 10 mg PO DAILY
4. Carvedilol 25 mg PO BID
5. HydrALAzine 50 mg PO Q8H
6. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
7. Torsemide 60 mg PO DAILY
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
RX *amlodipine 10 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
2. Aspirin 81 mg PO DAILY
RX *aspirin [Adult Low Dose Aspirin] 81 mg 1 tablet(s) by mouth
daily Disp #*30 Tablet Refills:*0
3. Carvedilol 25 mg PO BID
RX *carvedilol 25 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
4. HydrALAzine 50 mg PO Q8H
RX *hydralazine 50 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*90 Tablet Refills:*0
5. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
RX *isosorbide mononitrate 60 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
6. Tamsulosin 0.8 mg PO QHS
RX *tamsulosin 0.4 mg 2 capsule(s) by mouth at bedtime Disp #*60
Capsule Refills:*0
7. Torsemide 60 mg PO DAILY
RX *torsemide 20 mg 3 tablet(s) by mouth daily Disp #*90 Tablet
Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Congestive heart failure exacerbation
Hypertension
Chronic Kidney Disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: History: ___ with COUGH // PNA
FINDINGS:
Compared to the previous examination of ___. The heart appears
smaller enlarged and there is increased generalized haziness of the lung
fields indicating interstitial edema. No focal pneumonia. No pleural
effusions.
Conclusion: Enlarged heart with CHF.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Dyspnea, Cough
Diagnosed with Heart failure, unspecified
temperature: 98.3
heartrate: 95.0
resprate: 18.0
o2sat: 98.0
sbp: 164.0
dbp: 109.0
level of pain: 0
level of acuity: 3.0 | SUMMARY STATEMENT:
==================
___ yo male with history of CKD, HTN and diastolic CHF (EF 50%)
reporting cough, SOB, and orthopnea over the last month
worsening over the last few days presenting with diastolic CHF
exacerbation in the setting of diuretic noncompliance.
ACUTE ISSUES:
=============
# Diastolic CHF exacerbation:
Patient presented with dyspnea, cough, increased weight up 2
lbs. from dry weight, and pulmonary edema on CXR all consistent
with diastolic heart failure exacerbation in the setting of
intermittent medication non-compliance. Patient was diuresed
with 80mg IV Lasix daily. Last TTE from ___ noted EF of
(LVEF 50-55%). TTE during this admission with new mild global RV
systolic dysfunction. Overall left ventricular systolic function
remains low normal (LVEF 50-55%) secondary to mild global
hypokinesis. Patient needed to get home urgently on day of
discharge, so agreed to perform daily weights in AM and to
improve medication compliance. Weight at time of discharge
97.9kg (may not be dry weight).
# Cough:
Patient reported cough for last month. Thought to be secondary
to CHF exacerbation given no evidence of pneumonia on chest
xray, absence of leukocytosis, and afebrile. Sputum culture with
contamination with upper respiratory secretions. Was improving
at time of discharge.
# ___ on CKD: Baseline creatinine 4.3. Elevated to 5.3 on
admission and 5.2 at time of discharge. Was improving with
diuresis so felt to be due to volume overload. CKD is felt to be
due to uncontrolled hypertension and is being evaluated for
kidney transplantation. Renal FYI-ed of his admission during
this hospital stay.
CHRONIC ISSUES:
===============
# Troponemia:
Patient with chronically elevated troponins in setting of CKD.
Troponin at 0.10 at patient's baseline on admission, 0.12 on
recheck. Patient continued to be chest pain free during his
hospital admission and ECG was without ischemic changes on
admission.
# HTN
Blood pressure poorly controlled per patient's report at
baseline suspect from intermittent medication non-compliance.
Home medications of Amlodipine 10 mg daily, Carvedilol 25 mg
BID, Hydralazine 50 mg TID and Isosorbide mononitrate ER 60 mg
daily were continued during his hospital stay.
# BPH: Continued on Tamsulosin 0.8 mg daily
TRANSITIONAL ISSUES:
====================
#CHF exacerbation: felt to be secondary to medication
noncompliance. Discharge weight 97.9kg. Please follow up to
ensure patient taking daily weights and keeping up with
medication compliance. Scrips for all prescriptions were
provided to patient.
#Renal: Patient being considered for renal transplantation for
ESRD ___ HTN. Please follow up.
#FK levels: Tested given thickening noted on TTE to r/o amyloid
as etiology of heart failure. Additionally considered Fabry's
disease though without a typical family history of cardiac
disease in family history. FK pending at time of discharge.
Please follow up.
#Ischemic evaluation: Patient has not had ischemic evaluation.
Please consider performing in future.
#Code Status: DNR/DNI
#Contact: ___ ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Erythromycin Base / Lactose / vancomycin
Attending: ___
Chief Complaint:
Weakness/Fatigue
Major Surgical or Invasive Procedure:
Endotracheal intubation ___
Central Venous Catheter insertion ___
Peripherally Inserted Central Catheter placement ___
History of Present Illness:
Ms. ___ is a ___ yo F w/ PMH significant for primary biliary
cirrhosis s/p OLT in ___ (on chronic immunosuppresion), afib
s/p PPM (on coumadin) and recurrent skin infections who
presented to OSH with weakness. Per family, the patient was
complaining of back pain and presented to the OSH. There she was
found to be hypotensive. She was bolused IVFs, started on
dopamine and transferred to ___ for further management.
In the ED, initial vitals 0 70 85/40 20 100% RA (on dopamine)
and patient subsequently spiked a fever to 103.9. She was given
levofloxacin/cefepime and dexamethasone and started on levophed
as well as 4L of NS. Labs were notable for WBC 10.8 (8% bands),
Hct 49.3 (bl 38), plt 170 (bl 250), INR 2.6 (on coumadin),
creatinine 1.5 (bl 1.1), Na 132 (bl 130), K 6.2 (hemolyzed),
bicarb 18 (non-gap), lactate 3.4, ALT/AST ___ (hemolyzed),
Tbili 1.7, UA with trace blood, prot, 3 WBC, no bacteria.
On arrival to the MICU, the patient is intubated and sedated.
Review of systems: unable to obtain secondary to sedation.
Past Medical History:
-primary biliary cirrhosis s/p OLT in ___ (on chronic
immunosuppresion)
-tachyarrhythmias (AFib and AFlutter) s/p multiple ablations,
s/p pacemaker
-mild hypertrophic cardiomyopathy, EF >55%
-ascending aortic aneurysm, 4.2 x 4.3 cm in ___
-primary biliary cirrhosis s/p OLT ___ on chronic
immunosuppression
-thyroid colloid cyst
-stable lung nodules
-rosacea
-retroperitoneal adenopathy
-skin cancer
-Raynaud's syndrome
-h/o cellulitis of thumb and left lower extremity
-keratosis on Left ___ which has tract
-s/p hernia repair
-s/p TIPS prior to transplant
-s/p C-section
Social History:
___
Family History:
Mom had ovarian cancer. Dad had hypertension, hyperlipidemia,
dementia, and ___ disease.
Physical Exam:
ADMISSION EXAM:
Vitals- 99.8, 94/56, 70, 100% on 50%FI02, CMV 500/18 PEEP 8
General- chronically ill appearing, sedated and intubated
HEENT- pupils constricted and sluggish
CV- RRR, no appreciable MRG, displaced PMI with enlarged
cardiac heave
Lungs- clear to auscultation bialterally when ausculated
anteriorly
Abdomen- soft, previous scar well healed with thickness felt in
epigastrium and RUQ just inferior to visible scar. No ascites.
GU- foley in place draining clear urine
Ext- RLE with 3cm cut on anterior shin with surrounding
erythema a warmth, with some inudration no flucutance
Neuro- sedated
DISCHARGE EXAM:
Vitals: T 98.4 BP 122/84 HR 85 RR 20 SaO2 94% on RA
GEN: NAD
HEENT: Several vesicular lesions on superior OP/hard palate with
surrounding erythema.
Neck: Bilateral cervical LAD present
Lungs: CTAB, breathing comfortably
CV: Irregular rhythm, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: Soft, nontender,nondistended
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: Diffusely distributed telangiectasia, palmar erythema.
Neuro: Alert and oriented X3, No flapping. No focal neurological
signs.
Pertinent Results:
ADMISSION LABS:
___ 08:30PM BLOOD WBC-10.8 RBC-5.23# Hgb-17.0*# Hct-49.3*#
MCV-94 MCH-32.4* MCHC-34.4 RDW-14.8 Plt ___
___ 08:30PM BLOOD Neuts-86* Bands-8* Lymphs-2* Monos-4
Eos-0 Baso-0 ___ Myelos-0
___ 08:30PM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
___ 08:30PM BLOOD ___ PTT-44.4* ___
___ 08:30PM BLOOD Glucose-83 UreaN-28* Creat-1.5* Na-132*
K-6.2* Cl-104 HCO3-18* AnGap-16
___ 08:30PM BLOOD ALT-53* AST-96* AlkPhos-104 TotBili-1.7*
___ 08:30PM BLOOD Albumin-3.6 Calcium-8.9 Phos-2.4* Mg-1.3*
___ 04:46AM BLOOD tacroFK-5.9
___ 11:02PM BLOOD Type-ART pO2-276* pCO2-38 pH-7.26*
calTCO2-18* Base XS--9
___ 08:34PM BLOOD Lactate-3.4* K-5.9*
___ 11:02PM BLOOD O2 Sat-98
DISCHARGE LABS:
___ 07:00AM BLOOD WBC-7.3 RBC-4.24 Hgb-13.6 Hct-38.5 MCV-91
MCH-32.1* MCHC-35.3* RDW-14.7 Plt ___
___ 07:00AM BLOOD ___
___ 07:00AM BLOOD Glucose-71 UreaN-16 Creat-0.8 Na-139
K-3.0* Cl-99 HCO3-36* AnGap-7*
___ 07:00AM BLOOD Calcium-8.1* Phos-2.7 Mg-1.7
IMAGING:
TTE ___
The left atrium is mildly elongated. No left atrial
mass/thrombus seen (best excluded by transesophageal
echocardiography). The estimated right atrial pressure is at
least 15 mmHg. There is mild symmetric left ventricular
hypertrophy with normal cavity size and global systolic function
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. The ascending aorta is mildly dilated. The aortic
valve leaflets (3) are mildly thickened. No masses or
vegetations are seen on the aortic valve. Mild to moderate
(___) aortic regurgitation is seen directed toward the anterior
mitral leaflet. The mitral valve leaflets are mildly thickened.
There is no mitral valve prolapse. No mass or vegetation is seen
on the mitral valve. Mild to moderate (___) mitral
regurgitation is seen. Moderate [2+] tricuspid regurgitation is
seen. There is moderate pulmonary artery systolic hypertension.
There is a trivial/physiologic pericardial effusion. IMPRESSION:
Mild-moderate aortic regurgitation. Mild-moderate mitral
regurgitation. Moderate tricuspid regurgitation. Pulmonary
artery hypertension. Mild symmetric left ventricular hypertrophy
with preserved global biventricular systolic function. Dilated
ascending aorta. No discrete vegetation identified.
TEE ___
No atrial septal defect is seen by 2D or color Doppler. Overall
left ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. The
ascending aorta is mildly dilated. There are simple atheroma in
the aortic arch. The descending thoracic aorta is mildly
dilated. There are simple atheroma in the descending thoracic
aorta. The aortic valve leaflets (3) are mildly thickened. No
masses or vegetations are seen on the aortic valve. No aortic
valve abscess is seen. Mild to moderate (___) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. No mass or
vegetation is seen on the mitral valve. Mild to moderate (___)
mitral regurgitation is seen. No vegetation/mass is seen on the
pulmonic valve. There is no pericardial effusion. IMPRESSION: No
valvular vegetations. Mild to moderate mitral, aortic, and
tricuspid regurgitation. Normal global biventricular systolic
function.
CT SPINE ___
FINDINGS:
There is no lumbar spine fracture or malalignment. There is no
evidence of discitis, osteomyelitis, or paraspinal soft tissue
abnormality. There are no abnormal areas of enhancement. CT is
limited for the evaluation of epidural abscess. Incidentally
noted, is a sclerotic lesion within the left iliac wing likely
representing bone island or prior bony infarct. In addition,
small subcentimeter well-circumscribed renal hypodensities,
likely represent cysts. There is bilateral symmetric
retroperitoneal stranding which is slightly increased when
compared to reference CT from ___, and likely
represents third-spacing of ascites. IMPRESSION: 1. No osseous
signs of infection within the lumbar spine. No paraspinal soft
tissue abnormality or abnormal enhancement. CT lacks
sensitivity for evaluating epidural abscess. 2. Incidental note
is made of a sclerotic lesion in the left iliac wing, likely a
bone island or prior bony infarct.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amiodarone 200 mg PO DAILY
2. Azathioprine 50 mg PO BID
3. Calcium Carbonate 500 mg PO BID
4. Digoxin 0.125 mg PO DAILY
5. Lisinopril 2.5 mg PO DAILY
6. Metoprolol Succinate XL 50 mg PO DAILY
7. PredniSONE 5 mg PO DAILY
8. Tacrolimus 1 mg PO Q12H
9. Zolpidem Tartrate 5 mg PO HS:PRN insomnia
10. Furosemide 40 mg PO DAILY
11. Levofloxacin 500 mg PO DAILY
12. Magnesium Oxide 800 mg PO DAILY
13. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
14. Vitamin D 1000 UNIT PO DAILY
15. Warfarin 0.5 mg PO DAILY
Discharge Medications:
1. Azathioprine 50 mg PO DAILY
2. PredniSONE 5 mg PO DAILY
3. Tacrolimus 0.5 mg PO Q12H
4. Warfarin 0.5 mg PO DAILY16
5. CefazoLIN 2 g IV Q8H MSSA Sepsis
Needs 4 weeks of antibiotics. Start: ___. End:
___.
6. Maalox/Diphenhydramine/Lidocaine 15 mL PO QID Mouth pain
7. Metoprolol Succinate XL 50 mg PO DAILY
8. Heparin Flush (10 units/ml) 2 mL IV PRN and PRN, line flush
9. Amiodarone 200 mg PO DAILY
10. Calcium Carbonate 500 mg PO BID
11. Furosemide 40 mg PO DAILY
12. Lisinopril 2.5 mg PO DAILY
13. Magnesium Oxide 800 mg PO DAILY
14. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
15. Vitamin D 1000 UNIT PO DAILY
16. Zolpidem Tartrate 5 mg PO HS:PRN insomnia
17. ValACYclovir 1000 mg PO Q12H HSV Stomatitis Duration: 10
Days
Continue until ___.
18. Outpatient Lab Work
Weekly CBC/diff, Chem-7, creatinine, BUN, AST, ALT, albumin,
alkaline phosphatase, INR and fax results to ___ OPAT
___ to monitor antibiotic therapy.
ICD-9 995.1 (Sepsis)
19. Outpatient Lab Work
Q3 day tacrolimus trough levels, goal ___.
Fax results to Q3 Dr. ___ at ___.
ICD-9 V42.7 (Liver transplant)
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY
# Septic Shock due to Methicillin Sensitive Staphylococcus
aureus bacteremia, secondary to RLE wound
# Stomatitis
# Atrial fibrilation / Sick sinus with implanted Biventricular
Pacemaker
SECONDARY:
# Status-post Orthotopic Liver Transplantation for Primary
Biliary Cirrhosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
HISTORY: ___ female with line placement.
COMPARISON: ___ at 16:17.
FINDINGS:
Single portable view of the chest. New right IJ central venous line is seen
with catheter tip in the mid SVC. There is no pneumothorax. Indistinct
pulmonary vascular markings are suggestive of interstitial edema. Linear
right basilar opacity may be due to atelectasis. Cardiac silhouette is
slightly enlarged. Left chest wall dual lead pacing device is again noted.
No acute osseous abnormalities detected.
IMPRESSION:
Interstitial pulmonary edema. New right IJ line with tip in the mid SVC. No
pneumothorax.
Radiology Report
REASON FOR EXAMINATION: Evaluation of the patient with ETT placement.
Portable AP chest radiograph was compared to ___.
The ET tube tip is 3.5 cm above the carina. The NG tube passes below the
diaphragm terminating in the stomach. The pacemaker leads terminate in right
atrium and right ventricle. Cardiomediastinal silhouette is unchanged
including cardiomegaly. Interstitial pulmonary edema has progressed in the
interim, currently severe.
Radiology Report
HISTORY: ___ woman with MSSA bacteremia and back pain, evaluate for
abscess.
COMPARISON: Reference Abdominal CT ___
TECHNIQUE: Helical axial MDCT sections were obtained through the lumbar
spine. Reformatted images in sagittal and coronal axes were obtained.
Total Exam DLP: 934mGy-cm
CTDIvol 32mGy
FINDINGS:
There is no lumbar spine fracture or malalignment. There is no evidence of
discitis, osteomyelitis, or paraspinal soft tissue abnormality. There are no
abnormal areas of enhancement. CT is limited for the evaluation of epidural
abscess. Incidentally noted, is a sclerotic lesion within the left iliac wing
likely representing bone island or prior bony infarct. In addition, small
subcentimeter well-circumscribed renal hypodensities, likely represent cysts.
There is bilateral symmetric retroperitoneal stranding which is slightly
increased when compared to reference CT from ___, and likely
represents third-spacing of ascites.
IMPRESSION:
1. No osseous signs of infection within the lumbar spine. No paraspinal soft
tissue abnormality or abnormal enhancement. CT lacks sensitivity for
evaluating epidural abscess.
2. Incidental note is made of a sclerotic lesion in the left iliac wing,
likely a bone island or prior bony infarct.
Radiology Report
HISTORY: ___ woman with MSSA bacteremia and back pain.
COMPARISON: None available.
TECHNIQUE: Helical axial MDCT sections were obtained through the thoracic
spine. Reformatted images in sagittal and coronal axes were obtained.
Total Exam DLP: 1115mGy-cm
CTDIvol 32mGy
FINDINGS:
There is no thoracic spine fractures or malalignment. CT is low sensitivity
for an epidural abscess, however there are no osseous signs of infection. In
addition, there are no abnormal areas of enhancement. There are bilateral
pleural effusions and atelectasis. The soft tissues are unremarkable. There
is no lymphadenopathy noted by CT size criteria.
IMPRESSION:
1. CT is limited in the assessment for epidural abscess, however there are no
signs of osseous infection of the thoracic spine.
2. Bilateral pleural effusions.
Radiology Report
HISTORY: ___ woman with MSSA bacteremia and altered mental status,
assess for intracranial abnormality.
COMPARISON: NCHCT ___.
TECHNIQUE: Contiguous axial MDCT images were obtained through the brain
without administration of IV contrast. Reformatted coronal and sagittal and
thin section bone algorithm reconstructed images were acquired.
Total Exam DLP: 1026mGy-cm
CTDIvol: 63mGy
FINDINGS:
There is no evidence of intracranial hemorrhage, edema, mass effect, large
vascular territory infarction. Ventricles and sulci are normal in size and
configuration. The basal cisterns appear patent and there is preservation of
gray-white matter differentiation. The visualized intracranial vasculature
appears patent.
No fracture is identified. The included paranasal sinuses, mastoid air cells,
and middle ear cavities are clear. The orbits are unremarkable.
IMPRESSION:
No acute intracranial abnormality.
Gender: F
Race: WHITE
Arrive by UNKNOWN
Chief complaint: WEAKNESS
Diagnosed with SEPTICEMIA NOS, SEVERE SEPSIS , SEPTIC SHOCK, ACCIDENT NOS
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: 1.0 | Ms. ___ is a ___ yo F w/ PMH of liver transplant on
immunosuppression and afib s/p PPM on coumadin who presents with
injury to right leg and new fever and hypotension and meets
criteria for septic shock requiring pressors.
#Septic shock- Patient presented with elevated WBC, fevers to
103.9 and bandemia. Blood cultures grew MSSA. Given her chronic
steroid use for ___ years and previous episodes of hypotension
she was started on steroids for adrenal insufficiency. She
received up front sepsis goal directed therapy on arrival to our
ED. Initially dopamine and norepinephrine were required for
hemodynamic support. These were titrated off within 24 hours
with appropriate volume resuscitation. CT scan was negative for
clear intrabdominal source, urine clean, CXR and CT chest
without evidence of pneumonia. The patient was noted to have
small abrasion on her right lower extremity, potentially
providing a portal of entry and also recently had dental
surgery. Endocarditis (patient with pacemaker) and spinal
process were investigated with TTE and CT spine respectively. CT
spine and CT head showed no acute process. The infectious
disease service was consulted and recommended a TEE. The TEE
showed no vegeatiions. Blood cultured from ___ grew staph coag
positive. Pt initially on vanc and cefepime and then switched to
cefazolin per ID recs. Plan for cefazolin for 4 weeks ending
___. Elecrophysiology was consulted and talked to the ID
service and agreed NOT to remove pacemaker system, but would
reconsider this if she develops further signs of infection.
- 4 weeks of cefazolin 2 g IV Q8H. Start: ___. End:
___.
- Weekly CBC/diff, Chem-7, creatinine, BUN, AST, ALT, albumin,
alkaline phosphatase, INR and fax to ___ OPAT (outpatient
antibiotic therapy) ___ to monitor antibiotic therapy.
#Afib- patient with refractory atiral tachyarrhythmias in the
past, s/p multiple procedures indluing pace maker placement.
Initially metop and dig were held when she was hypotensive and
then restarted. HR were in the ___ and she was continued on
warfarin, metoprolol, amiodarone.
- Needs daily INR checks with goal INR ___. Adjust warfarin
dose accordingly.
#Stomatitis: Patient developed mouth pain ___ and ulcers were
noted on ___. Concerning for HSV stomatitis vs. ___
virus.
- Continue valacyclovir for ___nding ___.
- Continue lidocaine/maalox/diphenhidramine swish and spit for
symptom control.
- Continue nystatin swish and spit.
#Primary biliary cirrhosis s/p orthotopic transplant in ___.
Hepatology was involved in her care and recommedned holding
tacrolimus initially (level in the 5s) and then when level was
3.6 it was restarted, azathioprine was continued.
- Check tacro troughs with goal ___
#Thrombocytopenia: Likely from chronic liver disease and staph
bacteremia. Stable ~100.
#Hypokalemia: Consistently low. Has required repletion daily.
#Hypomagnesemia: Consistently low. Has required repletion
daily.
# CODE: Full Code (Confirmed)
# CONTACT: ___ (husband) Cell phone: ___
TRANSITIONAL ISSUES
===================
#) 4 weeks of cefazolin 2 g IV Q8H. Start: ___. End:
___.
#) Weekly CBC/diff, Chem-7, creatinine, BUN, AST, ALT, albumin,
alkaline phosphatase, INR and fax to ___ OPAT (outpatient
antibiotic therapy) ___ to monitor antibiotic therapy.
#) Daily K, Mg with appropriate repletion since she has
consistently required repletion.
#) Daily INR with adjustment of warfarin dose for goal INR ___
until she is stable for several days when INRs can then be
spaced to weekly.
#) Q3 day tacrolimus trough levels, goal ___.
Fax results to Q3 Dr. ___ at ___. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ with PMHx of CAD (s/p 5v CABG, AVR,
aortic arch graft), HTN, HLD, DM, CHF (EF 45-50%, multiple
myeloma, recently started on pomalidomide on ___, who presents
with dyspnea. Pt reports wt of 174 on ___ but was ___
yesterday. He denies salt/medication noncompliance. No
localizing infectious symptoms. Reports worsening dyspnea that
awoke him from sleep the night of ___ requiring him to sit in a
chair. He was having some mild left sided axillary chest pain
which is chronic in nature. EMS was called. He was started on
BiPAP in the field and given sl ntg for SPBs in the 180s.
In the ED, initial VS were 93 149/71 20 100% cpap. Labs were
notable for BNP of 14000 and Na 129. Cre was 2.0 (baseline).
CXR was c/w pulmonary edema. EKG showed LBBB. VS prior to
transfer were 98.1 91 118/65 19 100% cpap. In the ED, he was
given lasix 80 IV, to which he did not respond. He was
continued on BiPAP and transferred to the CCU.
Past Medical History:
1. CAD s/p CABG ___ (LIMA-LAD, SVG-dLAD, SVG-OM-D1, SVG-RDPA)
2. CHF (EF 45-50%)
3. Ascending aortic aneurysm s/p bioprosthetic AVR/ascending
aortic graft ___
4. Cardiac arrest ___ (? vagal episode)
5. CVA
6. DM
7. Dyslipidemia
8. HTN
9. CKD
10. LBBB
11. MM
12. R-sided vocal cord paralysis
13. GERD
14. Anemia
Social History:
___
Family History:
His father had diabetes. His mother had asthma. He has two
brothers, one is well and one died from unclear causes.
Physical Exam:
Admission Physical Exam:
98.2 92 136/84 20 100% on BIPAP ___ 40% FIO2
General: NAD
HEENT: EOMI, PERRL, BIPAP mask in place
Neck: supple
CV: RRR, ___ systolic murmur at RUSB
Lungs: crackles ___ way up bilateral posterior lung fields
Abdomen: obese, nt, nd, abdominal rounding with breathing
GU: no foley
Ext: 1+ edema bilaterally, distal pulses in tact
Neuro: moving all 4 extremities, A&Ox3
Skin: no rash
Discharge Physical Exam:
Tmax/Tcurrent:98.0 HR: ___ RR:21 ___ O2 sat:92-95%
RA
I/O:-1.5 litres
24hr: 1320/___
8hr ___
Weight:80.4k (79.3k)
___: 250-314
Tele: Sinus rhythm with LBBB 80-90's, prolonged PRI no VEA
General:No acute distress
HEENT: PERRLA
CV: RRR S1S2 III/VI systolic ejection murmur
Resp: Faint crackles in bases bilaterally L>R
ABD: soft, non-distended, normal bowel sounds
Extr: 1+ BLE edema to chins, feet warm. 1+DP bilaterally
JVD: None appreciated while sitting upright
Neuro: A+Ox3, denies pain.
Pertinent Results:
Admission labs:
___ 04:30AM ___ PTT-29.7 ___
___ 04:30AM WBC-10.1 RBC-2.83* HGB-7.3* HCT-25.5* MCV-90
MCH-26.0* MCHC-28.8* RDW-16.6*
___ 04:30AM NEUTS-77.7* LYMPHS-13.5* MONOS-4.1 EOS-4.1*
BASOS-0.5
___ 04:30AM PLT COUNT-341
___ 04:30AM CALCIUM-8.5 PHOSPHATE-5.8*# MAGNESIUM-3.3*
___ 04:30AM CK-MB-2 proBNP-1445*
___ 04:30AM cTropnT-<0.01
___ 04:30AM CK(CPK)-120
___ 04:30AM GLUCOSE-532* UREA N-36* CREAT-2.0*
SODIUM-129* POTASSIUM-4.5 CHLORIDE-88* TOTAL CO2-30 ANION GAP-16
Interim Labs:
___ 09:55AM CK-MB-2 cTropnT-<0.01
___ 09:55AM CK(CPK)-113
___ 09:55AM SODIUM-133 POTASSIUM-4.7 CHLORIDE-91*
___ 04:00PM CALCIUM-9.0 PHOSPHATE-4.2# MAGNESIUM-2.9*
___ 04:00PM GLUCOSE-293* UREA N-38* CREAT-2.0*
SODIUM-131* POTASSIUM-4.6 CHLORIDE-89* TOTAL CO2-34* ANION
GAP-13
Discharge Labs:
___ 03:12AM BLOOD WBC-6.3 RBC-2.69* Hgb-6.8* Hct-23.7*
MCV-88 MCH-25.4* MCHC-28.9* RDW-16.5* Plt ___
___ 03:12AM BLOOD Glucose-196* UreaN-44* Creat-2.0* Na-136
K-4.1 Cl-93* HCO3-35* AnGap-12
___ 03:12AM BLOOD Calcium-9.1 Phos-5.4* Mg-2.6
Micro:
MRSA Screen Negative
___ 8:09 am URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___:
PSEUDOMONAS AERUGINOSA.
10,000-100,000 ORGANISMS/ML. OF TWO COLONIAL
MORPHOLOGIES.
Piperacillin/Tazobactam sensitivity testing performed
by ___
___.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- 4 S
CEFTAZIDIME----------- 8 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ 2 S
MEROPENEM------------- 1 S
PIPERACILLIN/TAZO----- I
TOBRAMYCIN------------ <=1 S
Reports:
___ EKG
Sinus rhythm. Left atrial abnormality. Compared to the previous
tracing of ___, the rate has slowed. The ST-T wave changes
are less
prominent and left bundle-branch block persists. Otherwise, no
diagnostic
interimi change.
___ CXR
A prosthetic valve and median sternotomy wires are again noted.
The aortic knob is calcified. Motion limits evaluation of the
film. Left lower lobe linear opacities are unchanged and likely
represent atelectasis. There are patchy new alveolar
infiltrates bilaterally. There is prominent pulmonary
vasculature.small left pleural effusion.
IMPRESSION:
Fluid overlad. New opacities in the correct clinical setting
could represent pneumonia or could be due to CHF .
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Acyclovir 400 mg PO Q12H
2. Allopurinol ___ mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 20 mg PO DAILY
5. Carvedilol 12.5 mg PO BID
6. sevelamer CARBONATE 800 mg PO TID W/MEALS
7. Docusate Sodium 100 mg PO BID
8. Polyethylene Glycol 17 g PO DAILY:PRN constipation
9. Senna 8.6 mg PO BID:PRN constipation
10. Acetaminophen-Caff-Butalbital 1 TAB PO Q6H:PRN headaches
11. NexIUM (esomeprazole magnesium) 40 mg Oral daily
12. Prochlorperazine ___ mg PO Q6H:PRN n/v
13. Glargine 15 Units Breakfast
Glargine 15 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
14. Gabapentin 300 mg PO TID
15. Torsemide 100 mg PO DAILY
Discharge Medications:
1. Acetaminophen-Caff-Butalbital 1 TAB PO Q6H:PRN headaches
2. Acyclovir 400 mg PO Q12H
3. Allopurinol ___ mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Atorvastatin 20 mg PO DAILY
6. Carvedilol 12.5 mg PO BID
7. Docusate Sodium 100 mg PO BID
8. Polyethylene Glycol 17 g PO DAILY:PRN constipation
9. Prochlorperazine ___ mg PO Q6H:PRN n/v
10. Senna 8.6 mg PO BID:PRN constipation
11. sevelamer CARBONATE 800 mg PO TID W/MEALS
12. Gabapentin 300 mg PO TID
13. NexIUM (esomeprazole magnesium) 40 mg Oral daily
14. Torsemide 100 mg PO BID
RX *torsemide 100 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*3
15. Lisinopril 2.5 mg PO DAILY
RX *lisinopril 2.5 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*3
16. Ciprofloxacin HCl 500 mg PO Q12H Duration: 7 Days
RX *ciprofloxacin 500 mg 1 tablet(s) by mouth Q 12H Disp #*14
Tablet Refills:*0
17. Outpatient Lab Work
Chem 7
___ Please fax results to:
___. ___ Fax: ___
___. MD, ___ ___
ICD-9 428.32
18. Glargine 15 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Heart failure exacerbation
Secondary:
Diabetes
Multiple Myeloma
Chronic renal failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
CLINICAL INDICATION: Shortness of breath. Evaluation for congestive heart
failure.
COMPARISON: Multiple prior chest radiographs, the most recent of ___.
PORTABLE UPRIGHT FRONTAL VIEW OF THE CHEST:
A prosthetic valve and median sternotomy wires are again noted. The aortic
knob is calcified. Motion limits evaluation of the film. Left lower lobe
linear opacities are unchanged and likely represent atelectasis. There are
patchy new alveolar infiltrates bilaterally. There is prominent pulmonary
vasculature.small left pleural effusion.
IMPRESSION:
Fluid overlad. New opacities in the correct clinical setting could represent
pneumonia or could be due to CHF .
Gender: M
Race: OTHER
Arrive by AMBULANCE
Chief complaint: DYSPNEA
Diagnosed with CONGESTIVE HEART FAILURE, UNSPEC
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: 1.0 | Mr. ___ is a ___ with PMHx of CAD (s/p 5v CABG, AVR,
aortic arch graft), HTN, HLD, DM, CHF (EF 45-50%), multiple
myeloma with recent initiation of Pomalidomide, who presents
with acute on chronic systolic heart failure.
.
# Acute on chronic congestive heart failure with systolic
dysfunction: LVEF 45-50%. Pt with clinical e/o of left and
right sided CHF given pulm edema, ___ edema, and elevated JVP.
Dyspnea requiring BIPAP in the field and in ED. Failed trial off
BIPAP and transferred to CCU, quickly improved with IV
diuretics. The etiology of his exacerbation is unclear, as there
is no clear infectious trigger, dietary/medication
noncompliance. Given temporal relationship to initiation of
Pomalidomide, this may have been inciting factor. Per outpatient
oncologist, ok to hold Pomalidomide but it is not known to cause
CHF though could worsening ___ edema.
.
# CAD/HLD - Severe 3V CAD by cath in ___. Continued
carvedilol, ASA and atorvastatin.
.
# Multiple Myeloma - On pomalidomide since ___. Held
Pomalidomide in house per approval from Dr. ___
___ oncologist). Continued allopurinol and acyclovir.
He should follow up with Dr. ___ furher
management of MM.
.
# CKD stage 3 - Creatinine at baseline of 2.0 during admission.
Continued sevelamer.
.
# Anemia - HCT stable this admission and at baseline. Likely
___ CKD, chemo, and MM.
.
# DM2 c/b acute hyperglycemia - On glargine with humalog ss at
home. He was hyperglycemic to 500s on presentation without an
anion gap. Reports checking his BG after meals at home; uses
those post-prandial BG values to dose his humalog. Had a prior
admission for hypoglycemia and is therefore very concerned about
hypoglycemia. Declined diabetes education. Refused SSI as
ordered in house out of fear of hypoglycemia (he felt the
sliding scale was too aggressive as ordered and refused qac BG
checks). BG 200-300's this admission.
. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
weakness, constipation
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ old man with locally advanced pancreatic
adenocarcinoma with liver metastases C6D28 of
gemcitabine/nab-paclitaxil and cyberknife SBRT (completed on
___ who presents with generalized weakness. The patient
reports one week of generalized weakness limiting his ability to
ambulate. He also reports 5 days of constipation. He denies
abdominal pain, nausea, vomiting, fever, chills, chest pain,
shortness of breath, cough. In the ED, initial VS were: T 98.2
HR 111 BP 118/74 RR 18 SpO2 99% RA. Exam was notable for
external hemorrhoids, bright red blood on rectal exam, patient
was guaiac positive. Initial labs were notable for H/H of
8.7/27.8 (near baseline), lactate 2.1, elevated LFTs (ALT ___
AST 47, AP 504, TBili 0.4), albumin 2.5. GI was consulted for
hematochezia and recommended serial Hcts. Patient received 1 L
NS. CXR was unremarkable. The patient was admitted to OMED for
further management.
On arrival to the floor, patient reports ___ weakness and
unsteady gait. He reports he sustained a abdominal muscle strain
about one week ago in the setting of lifting. He saw his PCP and
was prescribed muscle relaxants. Since his injury, he reports he
has not been ambulating well. He denies any falls or headstrike.
He also experiences some difficulty standing up but denies any
lightheadedness, chest pain, dyspnea, falls, dysuria, abdominal
pain, fevers, chills, nausea, or vomiting. He reports ongoing
constipation with his last bowel movement about 4 days ago. He
denies any numbness around his buttock region and denies any
urinary incontinence.
Past Medical History:
- appendectomy
- tonsillectomy
- HTN
- hyperlipidemia
Social History:
___
Family History:
Father with MI
Physical Exam:
ON ADMISSION:
VS: T 97.5 HR 92 BP 114/76 RR 20 SpO2 not available
Wt 161.5 lbs
GENERAL: Elderly man in NAD
HEENT: Sclera icteric. MMM, no OP lesions.
CARDIAC: RRR, normal S1 & S2, without murmurs, S3 or S4
LUNG: clear to auscultation, no wheezes or rhonchi
ABD: +BS, soft, NT/ND, no rebound or guarding
EXT: No lower extremity pitting edema
PULSES: 2+DP pulses bilaterally
NEURO: CN II-XII intact. Full strength and sensation in UE and
___ bilaterally. Unstable gait with walking a few steps. No
saddle anesthesia
SKIN: Sacral pressure ulcer with granulation tissue otherwise
without obvious erythema or discharge.
ON DISCHARGE:
VS: T 98.7 Tc 97.9 HR ___ BP 108-140/58-70 RR ___ SpO2
97-98% RA
Wt 160.2 lbs, I/O 24h 640/850, 8h 100/500
GENERAL: Elderly man in NAD
HEENT: Sclera icteric. MMM, no OP lesions.
CARDIAC: RRR, normal S1 & S2, without murmurs, S3 or S4
LUNG: clear to auscultation, no wheezes or rhonchi
ABD: +BS, soft, NT/ND, no rebound or guarding
EXT: No lower extremity pitting edema
PULSES: 2+DP pulses bilaterally
NEURO: CN II-XII intact. Full strength and sensation in UE and
___ bilaterally. Unstable gait with walking a few steps. No
saddle anesthesia
SKIN: Sacral pressure ulcer with granulation tissue otherwise
without obvious erythema or discharge.
Pertinent Results:
ADMISSION LABS:
___ 02:00PM BLOOD WBC-8.5 RBC-2.98* Hgb-8.7* Hct-27.8*
MCV-93 MCH-29.1 MCHC-31.2 RDW-19.8* Plt ___
___ 02:00PM BLOOD Neuts-73.5* Lymphs-17.4* Monos-8.5
Eos-0.4 Baso-0.2
___ 02:00PM BLOOD Plt ___
___ 02:00PM BLOOD Glucose-112* UreaN-9 Creat-0.4* Na-135
K-3.9 Cl-103 HCO3-21* AnGap-15
___ 02:00PM BLOOD ALT-61* AST-47* AlkPhos-504* TotBili-0.4
___ 02:00PM BLOOD Albumin-2.5* Calcium-7.9* Phos-3.7 Mg-1.8
___ 02:23PM BLOOD Lactate-2.1*
___ 06:09AM URINE Color-Yellow Appear-Clear Sp ___
___ 06:09AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-7.0 Leuks-NEG
___ 06:09AM URINE ___ Bacteri-OCC Yeast-NONE
Epi-0
IMAGING:
CHEST (PA & LAT) ___:
IMPRESSION:
No acute cardiopulmonary process.
ABDOMEN (SUPINE & ERECT) ___:
IMPRESSION:
No evidence of obstruction or ileus. There is a large amount of
stool within the colon.
MICROBIOLOGY:
___ 2:00 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
DISCHARGE LABS:
___ 04:35AM BLOOD WBC-10.1 RBC-2.90* Hgb-8.7* Hct-26.9*
MCV-93 MCH-30.1 MCHC-32.5 RDW-19.4* Plt ___
___ 04:35AM BLOOD Plt ___
___ 04:35AM BLOOD Glucose-113* UreaN-9 Creat-0.4* Na-135
K-3.6 Cl-101 HCO3-22 AnGap-16
___ 04:35AM BLOOD ALT-40 AST-31 LD(LDH)-183 AlkPhos-518*
TotBili-0.4
___ 04:35AM BLOOD Calcium-7.8* Phos-3.5 Mg-1.7
___ 04:35AM BLOOD CA ___ -PND
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 10 mg PO DAILY
2. Lisinopril 20 mg PO DAILY
3. Metoprolol Succinate XL 50 mg PO DAILY
4. Atorvastatin 80 mg PO QPM
5. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
6. Omeprazole 40 mg PO DAILY
7. Ondansetron 8 mg PO Q8H:PRN Nausea
8. Prochlorperazine 10 mg PO Q6H:PRN Nausea
9. Docusate Sodium 100 mg PO BID
10. Senna 8.6 mg PO BID
11. Polyethylene Glycol 17 g PO DAILY:PRN Constipation
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
3. Docusate Sodium 100 mg PO BID
4. Lisinopril 20 mg PO DAILY
5. Metoprolol Succinate XL 50 mg PO DAILY
6. Omeprazole 40 mg PO DAILY
7. Ondansetron 8 mg PO Q8H:PRN Nausea
8. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
9. Senna 8.6 mg PO BID
10. Prochlorperazine 10 mg PO Q6H:PRN Nausea
11. Bisacodyl 10 mg PO DAILY
RX *bisacodyl 5 mg 2 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
12. Prescription for ___ Prescription. ICD-9 code Pancreatic Cancer 157. Patient
deconditioned and needs walker for ambulation.
13. Polyethylene Glycol 17 g PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Constipation
Weakness
Pancreatic adenocarcinoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
INDICATION: ___ with pancreatic CA on chemo p/w generalized weakness // r/o
PNA
TECHNIQUE: PA and lateral views of the chest.
COMPARISON: CT chest from ___.
FINDINGS:
Right chest wall port is seen with catheter tip in the right atrium. The
lungs are clear without focal consolidation or effusion. The
cardiomediastinal silhouette is within normal limits. Atherosclerotic
calcifications are noted at the aortic arch. No acute osseous abnormalities
identified. No free air seen below the diaphragm. Stent is partially
visualized in the upper abdomen.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
EXAMINATION: ABDOMEN (SUPINE AND ERECT)
INDICATION: ___ year old man with ___ old man with locally advanced
pancreatic adenocarcinoma with liver metastases C6D28 of
gemcitabine/nab-paclitaxil and cyberknife SBRT (completed on ___ with
abdominal pain, constipation // evaluate for obstruction, ileus, stool
TECHNIQUE: Two views of the abdomen
COMPARISON: CT abdomen and pelvis ___.
FINDINGS:
There is a CBD stent noted in the right upper quadrant. The bowel gas pattern
is nonspecific and nonobstructive. There are no abnormally dilated loops of
small or large bowel. There is no evidence of pneumatosis or pneumoperitoneum.
There is a large amount of stool within the colon.
IMPRESSION:
No evidence of obstruction or ileus. There is a large amount of stool within
the colon.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Weakness, Pain
Diagnosed with OTHER MALAISE AND FATIGUE, RECTAL & ANAL HEMORRHAGE
temperature: 98.2
heartrate: 111.0
resprate: 18.0
o2sat: 99.0
sbp: 118.0
dbp: 74.0
level of pain: 0
level of acuity: 2.0 | Mr. ___ is a ___ old man with locally advanced pancreatic
adenocarcinoma with liver metastases C6D28 of
gemcitabine/nab-paclitaxil and cyberknife SBRT (completed on
___ presenting with generalized weakness.
# Generalized Weakness: Prior to presentation, patient was
active and able to ambulate without difficulty. Patient reports
decrease ___ weakness and unstable gait since lifting injury.
Likely deconditioning. Given pancreatic malignancy, ddx also
includes spinal mets, however patient denies urinary
incontinence and constipation has been ongoing, no saddle
anesthesia. Patient otherwise without localizing signs of
infection. He worked with physical therapy who initially
recommended discharge to rehab but patient declined. After
working with physical therapy, patient was deemed safe for
discharge home with a walker and home ___.
# Constipation: Patient on chronic narcotics and has not had
bowel movement in 5 days at time of admission. KUB unremarkable
for obstruction but notable large amounts of stool. The patient
was managedon Senna, Colace, Miralax, PR Bisacodyl, and
lactulose x1. The patient required fecal dis-impaction resulting
in a bowel movement.
# Pancreatic Adenocarcinoma: Patient is C6C28 of
Gemcitabine/Nab-Paclitaxil. Patient with known liver mets. The
patient was started on C7C1 of Gemcitabine/Nab-Paclitaxil on
___.
# Sacral Wound: Patient has open sacral ulcer, clean-appearing
granulation tissue, no purulent discharge or erythema. The
patient was managed per wound care recommendations.
# Transaminitis: LFTs mildly more elevated (ALT 61 AST 47 AP
504) than previous. Possibly related to known liver mets. LFTs
were trending downwards at the time of discharge.
CHRONIC ISSUES
# Hypertension/Cardiac Regimen:
-Continued home Amlodipine 10 mg PO QDaily
-Continued home Lisinopril 20 mg PO QDaily
-Continued home Metoprolol Succinate 50 mg PO QDaily
-Continued home Atorvastatin 80 mg PO QPM
TRANSITIONAL ISSUES:
-Code Status: Full
- Discharged on bowel regimen: colace, senna, miralax and add
bisacodyl if no BM for 1 day.
- Received chemotherapy ___ C7D1 Abraxane/Gemcitabine
- ___ pending at discharge
- Seen by physical therapy and discharged home with walker |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Double Vision
Major Surgical or Invasive Procedure:
___ - Lumbar Puncture
___ - Lumbar Puncture
History of Present Illness:
Mrs. ___ is ___ year-old lady with a history of high grade
DLBCL (diagnosed ___, currently on C3D16 R-CHOP s/p C1 of
prophylactic HD-MTX and ulcerative colitis who is presenting
with visual changes and headache.
She was in a parking lot on her car on the day prior to
admission, at which point she noted that the road signs looked
"double" for her. Had her daughter take over and drive home
where it resolved. Otherwise, she was in her usual state of
health when she went to bed last night. On the morning of
admission, she awoke reporting double vision (around 0830). Also
reporting a mild headache, centered behind her right eye. She
denies any fevers or chills, neck stiffness, difficulty walking,
weakness or paresthesias.
She was recently hospitalized at ___ for fever (negative
infectious work-up, treated for 2 days with antibiotics and
ultimately afebrile and discharged off antibiotics). Seen in the
office on ___ by Dr ___ for ___ from
previous hospitalization, where pt was reporting ongoing shin
pain, which had been present during hospitalization. Per note,
Dr ___ reaction to Neulasta in the setting of
tapering steroids. Had been taking ibuprofen and naproxen for
the past few days with little improvement.
ED initial vitals: T 96.3, HR 96, BP 128/79, RR 18,SpO2 100% RA.
ED labs were significant for:
- CBC: WBC: 10.2*. HGB: 6.9*. Plt Count: 428*. Neuts%: 82*.
- Chemistry: Na: 138. K: 3.9. Cl: 100. CO2: 25. BUN: 11. Creat:
0.4. Ca: 8.6. Mg: 2.2. PO4: 4.2.
- Lactate: 1.4
- Imaging: CT head w/o contrast -- no acute intracranial
abnormality.
- Patient was given: nothing
- Consults: neurology, recommended MRI w/ and w/o contrast and
LP afterwards
- Decision was made to admit to ___ for ongoing work-up of
diplopia
On arrival to the floor, patient reports ongoing diplopia
without blurry vision. Headache has resolved. She continue to
have mild pain in her right shin as well as pins/needles
sensation in bilateral toes.
Patient denies fevers/chills, night sweats,
dizziness/lightheadedness, weakness/numbnesss, shortness of
breath, cough, hemoptysis, chest pain, palpitations, abdominal
pain, nausea/vomiting, diarrhea, hematemesis,
hematochezia/melena, dysuria, hematuria, and new rashes.
Past Medical History:
PAST ONCOLOGIC HISTORY:
-___: Referred to Dr ___ in our dept for
probable malignancy. 30 pound wt loss over the past year and 8
pound drop over the fall. Developed worsening confusion and
unsteadiness in early ___ and found to be hypercalcemic (Ca ___.
Admitted to ___ where she was given iv fluids,
Calcitonin and Pamidronate. Low PTH and normal PTHrp. Her CBC
showed early myeloid forms and some nuc rbc and her LDH was
elevated at 656. CT scans of chest, abd, pelvis did not show any
adenopathy or splenomegaly. There was a 5mm low attenuation
lesion in the panc head and a 1.3 cm lesion in the right adrenal
gland. There was a large 8.7x7.7x6.5 mass inseparable from the
uterus where a fibroid had been noted previously. Subsequent MRI
showed diffused dilatation of the panc duct raising concern for
IPM of the main panc duct and endoscopic ultrasound was
suggested as well as a dedicated adrenal washout CT for the
small adrenal lesion.
-Dr. ___ a BM asp and Bx that day which did not
show any abnormal lymphocytes in the aspirate and the
cytogenetics and FISH were normal. However, the biopsy showed a
multifocal infiltrate of malignant lymphocytes with Ki67 of
50-60%, felt to be an aggressive B cell lymphoma of germinal
center origin.
-___: Upper endoscopy showed mult gastric ulcers - bx
showed lymphoma, cytogenetics showed BCL6, no myc or BCL2
translocations.
-___: First cycle Rit/CHOP with split dose Rituxan.
-___ for febrile neutropenia despite neulasta
then ulc colitis flare. Restarted Pred.
-___: Fever, diarrhea due to C.dif. Rx'd po vanco
and pneumonia, rx'd Levoflox.
-___: cycle 2 Rit/CHOP.
PAST MEDICAL HISTORY:
- Ulcerative Colitis
- Rhinitis, allergic
- Eczema
- Headache, common migraine. *MRI performed ___ due to
complaints of headache, and was unremarkable.
- Hyperlipidemia
- Fatty Liver
- Fibroids
- Osteoarthritis
- Adrenal Nodule
- Pancreatic Cyst
Social History:
___
Family History:
Paternal aunt with breast CA. Sister with breast CA in her ___.
Physical Exam:
========================
Admission Physical Exam:
========================
VS: 98.1 PO 110 / 70 94 18 99 RA
GENERAL: Well-appearing lady, in no distress lying, in bed
comfortably.
HEENT: Anicteric, PERLL, Mucous membranes moist, OP clear.
CARDIAC: Regular rate and rhythm, normal heart sounds, no
murmurs, rubs or gallops.
LUNG: Appears in no respiratory distress, clear to auscultation
bilaterally, no crackles, wheezes, or rhonchi.
ABD: Non-distended, normal bowel sounds, soft, non-tender, no
guarding, no palpable masses, no organomegaly.
EXT: Warm, well perfused. No lower extremity edema. No erythema
or tenderness.
NEURO: A&Ox3, good attention and linear thought. No apparent
palsy of the III, IV, VI oculomotors, diplopia at baseline,
convergence, horizontal and vertical gaze. Absent nystagmus.
Otherwise CN V,VII-XII intact. Strength full throughout.
Sensation to light touch intact.
SKIN: No significant rashes.
========================
Admission Physical Exam:
========================
VS: Temp 98.0, BP 100/60, HR 89, RR 16, O2 sat 100% RA.
GENERAL: Pleasant lady, in no distress lying, in bed
comfortably.
HEENT: Anicteric, PERLL, OP clear. Right ptosis.
CARDIAC: RRR, normal s1/s2, no m/r/g.
LUNG: Appears in no respiratory distress, clear to auscultation
bilaterally, no crackles, wheezes, or rhonchi.
ABD: Soft, non-tender, non-distended, normal bowel sounds, no
hepatomegaly, no splenomegaly.
EXT: Warm, well perfused, no lower extremity edema, erythema or
tenderness.
NEURO: A&Ox3, good attention and linear thought. Right eye
ptosis stable, improved from several days ago. RLE weakness
4+/5. LLE ___ strength. Both upper
extremities ___ strength. No other deficits noted.
SKIN: No significant rashes.
ACCESS: Right chest wall port without erythema.
Pertinent Results:
===============
Admission Labs:
===============
___ 12:00PM BLOOD WBC-10.2* RBC-2.07* Hgb-6.9* Hct-22.7*
MCV-110* MCH-33.3* MCHC-30.4* RDW-19.7* RDWSD-78.7* Plt ___
___ 12:00PM BLOOD Neuts-82* Bands-0 Lymphs-8* Monos-8 Eos-0
Baso-1 ___ Myelos-1* NRBC-1* AbsNeut-8.36*
AbsLymp-0.82* AbsMono-0.82* AbsEos-0.00* AbsBaso-0.10*
___ 05:46AM BLOOD ___ PTT-31.4 ___
___ 12:00PM BLOOD Glucose-257* UreaN-11 Creat-0.4 Na-138
K-3.9 Cl-100 HCO3-25 AnGap-17
___ 12:00PM BLOOD Calcium-8.6 Phos-4.2 Mg-2.2
___ 12:17PM BLOOD Lactate-1.4
==============
Interval Labs:
==============
___ 05:27AM BLOOD %HbA1c-6.9* eAG-151*
___ 06:27AM BLOOD RheuFac-<10 ___
====================
Methotrexate Levels:
====================
___ 12:29PM BLOOD mthotrx-0.53
___ 12:07PM BLOOD mthotrx-0.07
___ 05:37AM BLOOD mthotrx-0.02
===============
Discharge Labs:
===============
___ 05:41AM BLOOD WBC-3.8* RBC-2.74* Hgb-9.0* Hct-29.3*
MCV-107* MCH-32.8* MCHC-30.7* RDW-15.9* RDWSD-63.3* Plt ___
___ 05:41AM BLOOD Glucose-124* UreaN-9 Creat-0.5 Na-142
K-4.1 Cl-103 HCO3-27 AnGap-16
___ 05:41AM BLOOD ALT-66* AST-42* AlkPhos-90 TotBili-0.2
___ 05:41AM BLOOD Calcium-9.1 Phos-5.2* Mg-2.2
============
___ Studies:
============
___ 01:50PM CEREBROSPINAL FLUID (CSF) WBC-2 RBC-2* Polys-0
___ ___ 01:50PM CEREBROSPINAL FLUID (CSF) TotProt-79*
Glucose-94
___ 01:25PM CEREBROSPINAL FLUID (CSF) WBC-2 RBC-104*
Polys-2 ___ Monos-25 Basos-2 ___ Macroph-2 Other-5
___ 01:25PM CEREBROSPINAL FLUID (CSF) WBC-2 RBC-23* Polys-1
___ Monos-17 Eos-1 Basos-1 ___ Macroph-1 Other-7
___ 01:25PM CEREBROSPINAL FLUID (CSF) TotProt-61*
Glucose-66 LD(LDH)-21
___ 01:50PM CEREBROSPINAL FLUID (CSF) HIV1 VL-NOT DETECT
___ EBV PCR- Negative
___ Borrelia Burg___ Antibody - Pending
___ Angiotensin 1 Converting Enzyme - 11 (Negative)
___ CMV PCR- Negative
___ HSV PCR - Negative
___ Paraneoplastic Autoantibody Evaluation - Negative
___ VZV PCR - Negative
___ Toxoplasma Gondii PCR - Negative
___ VDRL - Non-Reactive
=============
Microbiology:
=============
___ Blood Culture - No Growth
___ Urine Culture - Coag Negative Staph
___ CSF Culture - No Growth
___ Quantiferon-TB Gold - Negative
========
Imaging:
========
Head CT w/o Contrast ___
Impression: No acute intracranial abnormality on noncontrast
head CT.
MRI Head w/o Contrast ___
Impression: No evidence for intracranial metastatic disease. 5
mm right parietal dural calcification versus completely
calcified meningioma is stable.
MRI Orbit w/ and w/o Contrast ___
1. Thickening and enhancement of the left oculomotor nerve from
the interpeduncular cistern to the cavernous sinus. Mild
enhancement of the right oculomotor nerve near the cavernous
sinus. Given the patient's clinical history, this may represent
lipomatous involvement.
2. No cavernous sinus lesion identified.
CT Head/Neck ___
1. Dental amalgam streak artifact limits study.
2. No evidence of acute intracranial hemorrhage.
3. No evidence ofaneurysm greater than 3 mm, dissection or
significant luminal narrowing.
4. Left parotid gland oval soft tissue nodule may reflect a
lymph node but remains incompletely characterized. Ultrasound or
MRI can be obtained on a nonemergent basis for further
evaluation.
===================
Cytology/Pathology:
===================
___ CSF Cytology - Negative for malignant cells. Lymphocytes
and monocytes.
___ CSF Flow Cytometry - Immunophenotypic findings are of
involvement by a small population of kappa light chain
restricted B cells. Review of corresponding cytospin preparation
reveals medium to large atypical lymphoid cells with one to
several prominent nucleoli and dark blue cytoplasm with
vacuolations. Correlation with clinical, cytogenetic, and other
ancillary findings is recommended.
___ CSF Cytogenetics - Negative for BCL6 rearragnement.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN Headache
2. Cyclosporine 0.05% Ophth Emulsion 0.05 % ophthalmic Q12H
3. Fluticasone Propionate NASAL 2 SPRY NU DAILY
4. Simvastatin 40 mg PO QPM
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Headache
2. Cyclosporine 0.05% Ophth Emulsion 0.05 % ophthalmic Q12H
3. Fluticasone Propionate NASAL 2 SPRY NU DAILY
4. Simvastatin 40 mg PO QPM
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
- Lymphomatous Meningitis:
- Diploplia:
- CN III Palsy
- High Grade B-Cell Lymphoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: History: ___ with right headache, diplopia. // CVA?
TECHNIQUE: Routine unenhanced head CT was performed and viewed in brain,
intermediate and bone windows. Coronal and sagittal reformats were also
performed.
DOSE: sequence:
1) Sequenced Acquisition 16.0 s, 16.0 cm; CTDIvol = 50.2 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: MRI head ___
FINDINGS:
5 mm calcified focus arising from the right parasagittal parietal inner table
(series 3, image 47) corresponds to a focus gradient echo susceptibility
artifact seen on prior MRI, likely representing a calcified meningioma. There
is no intra or extra-axial mass effect, acute hemorrhage or large territory
infarct. Ventricles and sulci are within expected limits for the patient's
age. The imaged paranasal sinuses are clear. Mastoid air cells and middle ear
cavities are well aerated. The bony calvarium is intact.
IMPRESSION:
No acute intracranial abnormality on noncontrast head CT.
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST T9112 MR HEAD
INDICATION: History of high-grade diffuse large B-cell lymphoma post
chemotherapy presenting with new onset diplopia. Evaluate for infarct or
leptomeningeal spread of disease, in particular the cavernous sinus.
TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After
administration of 5 mL of Gadavist intravenous contrast, axial imaging was
performed with gradient echo, FLAIR, diffusion, and T1 technique. Sagittal
MPRAGE imaging was performed and re-formatted in axial and coronal
orientations.
COMPARISON: MR head ___. Noncontrast head CT ___.
FINDINGS:
Previously noted focus of susceptibility artifact along the right parietal
dura corresponds to a 5 mm dural calcification on recent CT examination
(6:16), without evidence of contrast enhancement on MP RAGE images (10:139).
There is no evidence for an enhancing mass or abnormal meningeal contrast
enhancement. There is no evidence for edema, acute infarction, or new blood
products. Ventricles and sulci are normal in size. A single punctate focus
of left frontal subcortical white matter FLAIR hyperintensity is unchanged,
nonspecific, though may reflect changes from chronic small vessel ischemic
disease (7:20).
The principal intracranial vascular flow voids are preserved. Dural venous
sinuses appear patent on postcontrast MP RAGE images.
This routine brain MRI is not optimized for detailed evaluation of the
cavernous sinuses. The cavernous sinuses appear normal in size without
evidence for a large mass.
IMPRESSION:
No evidence for intracranial metastatic disease. 5 mm right parietal dural
calcification versus completely calcified meningioma is stable.
RECOMMENDATION(S): If clinically warranted, a dedicated cavernous sinus
protocol MRI with fat-suppressed postcontrast images could better assess the
cavernous sinuses.
Radiology Report
EXAMINATION: MR ORBIT ___ ANDW/O CONTRAST T9123 MR ___
INDICATION: History of diffuse large B-cell lymphoma presenting with new
diplopia and right eyelid ptosis.
TECHNIQUE: Multiplanar, multi-sequence MRI of the orbits was performed before
and after the uneventful administration of 5 mL Gadavist intravenous contrast
agent. Images acquired at 3 mm slice thickness. Precontrast sequences included
axial and coronal T1, coronal STIR. Postcontrast sequences included axial and
coronal T1 with fat saturation.
COMPARISON: MR head ___ and ___.
FINDINGS:
ORBITS: There is asymmetric thickening and enhancement of the left oculomotor
nerve (series 7, image 9 and 10; cyst series 8, image 23), from the
interpeduncular cistern to the cavernous sinus which may represent
lymphomatous involvement. In addition, there is less prominent enhancement
along the right oculomotor nerve as it enters the cavernous sinus (series 7,
image 9). The remainder of the visualized cranial nerves are grossly
unremarkable.
The bony orbits and preseptal soft tissues are normal. The globes are intact
and normal in appearance. The optic nerves and complex are normal, without
edema or abnormal enhancement. The extraocular muscles are uniform in size and
normal in signal. The lacrimal apparatus is normal. Retrobulbar soft tissues
are normal.
OTHER FINDINGS:
The imaged portion of the brain is normal, without masses, abnormal
enhancement, or edema, better assessed on the recent dedicated head MR. ___
cavernous sinuses are unremarkable. There is trace mucosal wall thickening in
the floors of the bilateral maxillary sinuses. The remainder of the imaged
paranasal sinuses and mastoid air cells are clear.
IMPRESSION:
1. Thickening and enhancement of the left oculomotor nerve from the
interpeduncular cistern to the cavernous sinus. Mild enhancement of the right
oculomotor nerve near the cavernous sinus. Given the patient's clinical
history, this may represent lipomatous involvement.
2. No cavernous sinus lesion identified.
NOTIFICATION: The findings were discussed with ___, M.D. by
___, M.D. on the telephone on ___ at 6:51 ___, 20 minutes after
discovery of the findings.
Radiology Report
EXAMINATION: CTA HEAD AND CTA NECK Q16 CT NECK
INDICATION: ___ year old woman with diffuse large B cell lymphoma with new R
eye ptosis // to rule out aneurysm.
TECHNIQUE: Contiguous MDCT axial images were obtained through the brain
without contrast material. Subsequently, helically acquired rapid axial
imaging was performed from the aortic arch through the brain during the
infusion of 70 mL of Omnipaque intravenous contrast material.
Three-dimensional angiographic volume rendered, curved reformatted and
segmented images were generated on a dedicated workstation. This report is
based on interpretation of all of these images.
DOSE: Acquisition sequence:
1) Spiral Acquisition 9.8 s, 20.1 cm; CTDIvol = 51.9 mGy (Head) DLP =
1,047.7 mGy-cm.
2) Sequenced Acquisition 0.5 s, 0.4 cm; CTDIvol = 8.2 mGy (Head) DLP = 3.3
mGy-cm.
3) Stationary Acquisition 0.9 s, 0.2 cm; CTDIvol = 19.6 mGy (Head) DLP =
3.9 mGy-cm.
4) Spiral Acquisition 7.0 s, 37.0 cm; CTDIvol = 33.4 mGy (Head) DLP =
1,246.0 mGy-cm.
Total DLP (Head) = 2,301 mGy-cm.
COMPARISON: MR head with contrast performed ___.
FINDINGS:
Dental amalgam streak artifact limits study.
CT HEAD WITHOUT CONTRAST:
There is no evidence of no evidence of infarction, hemorrhage, edema, or mass.
The ventricles and sulci are normal in size and configuration.
The visualized portion of the paranasal sinuses, mastoid air cells, and middle
ear cavities are clear. The orbits are unremarkable.
CTA HEAD:
The vessels of the circle of ___ and their principal intracranial branches
appear normal without stenosis, occlusion, or aneurysm formation. The dural
venous sinuses are patent.
CTA NECK:
The carotid and vertebral arteries and their major branches appear normal with
no evidence of stenosis or occlusion. There is no evidence of internal carotid
stenosis by NASCET criteria.
OTHER:
Mild paraseptal emphysema involves the lung apices bilaterally and
symmetrically. A right chest port traverses the right chest wall and into the
right internal jugular vein, its tip incompletely imaged. A 1.1 x 0.9 cm soft
tissue oval density within the left parotid gland (5:151) may reflect a lymph
node although remains incompletely characterized. The visualized portion of
the thyroid gland is within normal limits. There is no lymphadenopathy by CT
size criteria.
IMPRESSION:
1. Dental amalgam streak artifact limits study.
2. No evidence of acute intracranial hemorrhage.
3. No evidence ofaneurysm greater than 3 mm, dissection or significant
luminal narrowing.
4. Left parotid gland oval soft tissue nodule may reflect a lymph node but
remains incompletely characterized. Ultrasound or MRI can be obtained on a
nonemergent basis for further evaluation.
Gender: F
Race: OTHER
Arrive by WALK IN
Chief complaint: Visual changes
Diagnosed with Diplopia
temperature: 96.3
heartrate: 96.0
resprate: 18.0
o2sat: 100.0
sbp: 128.0
dbp: 79.0
level of pain: 0
level of acuity: 2.0 | Ms. ___ is ___ lady with a history of high
grade DLBCL (diagnosed ___, currently on C3D16 R-CHOP s/p
C1 of prophylactic HD-MTX and ulcerative colitis who presents
with visual changes and headache and found to have lymphomatous
meningitis.
# Lymphomatous Meningitis:
# Diploplia:
# CN III Palsy: CT head and MRI on admission were overall
negative. MRI orbit noted thickening and enhancement of the left
oculomotor nerve. Neuro Oncology were consulted. Third nerve
palsy and enhancement in the left third nerve are suggestive of
leptomeningeal involvement by her DLCL. She had two LPs which
were sent for many infectious studies which were negative.
Cytology and pathology were concerning for lymphomatous
meningitis but final results were pending at time of discharge
She was started on Rituxan and HD MTX which she tolerated well
and methotrexate levels now less than 0.1. She was seen by
Opthamology with no evidence of intraocular lymphoma, given
instruction on partial patching of right eye to help with
diplopia. If no improvement in diplopia can ___ with
Ophthalmology at ___ for further evaluation. She will
plan for Rituxan weekly for ___s readmission for
methotrexate every 2 weeks.
# High Grade B-Cell Lymphoma: Currently receiving chemotherapy
with Rituximab-CHOP, with last dose of chemotherapy given on
___. She has been given high dose MTX on ___, with mild
increase in LFTs, and then administered R-CHOP on ___. Due for
next round of chemo on ___ but now delayed. Systemic
chemotherapy will be held given need for methotrexate as above.
She will also ___ with ___ Oncology department as well
as Atrius Oncology.
# Ulcerative Colitis: Recent flare in ___, during admission
thought to be related to first chemotherapy cycle as well as CDI
at which point was started on prednisone taper. Finished taper
on day of admission.
# Diabetes: Last hemoglobin a1c 7.6% on ___. Patient
reports never having been diagnosed with diabetes. Likely has
elevated A1c and hyperglycemia in the setting of prednisone
taper.
# Hypperlipidemia: Continued home simvastatin.
# Allergic Rhinitis: Continued fluticasone nasal spray daily.
# Sjogren Syndrome: Continued cyclosporine eye drops.
# Macrocytic Anemia: Likely secondary to malignancy and
chemotherapy. No evidence of active bleeding.
==================== |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
bacitracin
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
laparoscopic appendectomy
History of Present Illness:
Mr. ___ is a ___ year old male with no significant medical
history who presents with generalized abdominal pain. He reports
that the pain started yesterday and has been near the lower
midline portion of the abdomen. It is associated with anorexia,
bloating and subjective fevers, diaphoresis but no n/v or
changes in BMs. He has never had similar pain. He reported
eating seafood a couple of days ago but his wife did not develop
similar symptoms. ROS is positive for headaches, URI symptoms,
and fatigue starting late last week, for which he has been
taking ibuprofen. He has no personal or family history of IBD
and has never had a colonoscopy. His grandfather had colon
cancer in his
___. He last ate at breakfast time ___ a bagel).
Past Medical History:
none
Social History:
___
Family History:
Colon cancer in grandfather in ___. Otherwise
noncontributory
Physical Exam:
Vitals: T 97.8, HR 80, BP 117/64, RR 18, SpO2 98% RA
GEN: A&Ox3, lying comfortably in bed
HEENT: No scleral icterus
CV: RRR
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, non-distended, appropriately mildly tender to
palpation. Surgical incisions clean, dry, well approximated
EXT: No ___ edema, ___ warm and well perfused
Pertinent Results:
___ 11:00AM BLOOD WBC-7.5 RBC-5.20 Hgb-15.3 Hct-45.6 MCV-88
MCH-29.4 MCHC-33.6 RDW-12.6 RDWSD-40.3 Plt ___
___ 11:00AM BLOOD Neuts-62.2 ___ Monos-9.3 Eos-1.6
Baso-0.4 Im ___ AbsNeut-4.68 AbsLymp-1.97 AbsMono-0.70
AbsEos-0.12 AbsBaso-0.03
___ 11:00AM BLOOD Plt ___
___ 11:00AM BLOOD ___ PTT-34.7 ___
___ 11:00AM BLOOD Glucose-109* UreaN-13 Creat-1.0 Na-139
K-4.4 Cl-99 HCO3-28 AnGap-12
___ 11:00AM BLOOD ALT-24 AST-18 AlkPhos-52 TotBili-0.5
___ 11:00AM BLOOD Lipase-33
___ 11:00AM BLOOD Albumin-4.7
Medications on Admission:
Ibuprofen PRN Headaches
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever
Do not exceed more than 4000mg/day. Careful when taking other
meds that contain Tylenol.
2. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Severe
Please only take the minimum amount necessary to treat your
pain.
RX *oxycodone 5 mg 1 (One) tablet(s) by mouth every six (6)
hours Disp #*10 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
acute appendicitis s/p appendectomy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ with abd pain, frequent NSAID use// please perform upright
CXR to eval for free air under the diaphragm
TECHNIQUE: PA and lateral views the chest.
COMPARISON: None
FINDINGS:
Lungs are clear. There is no consolidation, effusion, or edema. The
cardiomediastinal silhouette is within normal limits. No acute osseous
abnormalities. No free intraperitoneal air.
IMPRESSION:
No acute cardiopulmonary process. No free intraperitoneal air.
Radiology Report
EXAMINATION: CT ABD AND PELVIS WITH CONTRAST
INDICATION: ___ with abdominal pain
TECHNIQUE: Single phase contrast: MDCT axial images were acquired through the
abdomen and pelvis following intravenous contrast administration.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Stationary Acquisition 3.5 s, 0.5 cm; CTDIvol = 16.9 mGy (Body) DLP =
8.4 mGy-cm.
2) Spiral Acquisition 6.7 s, 53.1 cm; CTDIvol = 22.0 mGy (Body) DLP =
1,165.2 mGy-cm.
3) Spiral Acquisition 0.9 s, 7.1 cm; CTDIvol = 15.3 mGy (Body) DLP = 109.0
mGy-cm.
Total DLP (Body) = 1,283 mGy-cm.
COMPARISON: None.
FINDINGS:
LOWER CHEST: Visualized lung fields are within normal limits. There is no
evidence of pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesions. There is no evidence of intrahepatic or
extrahepatic biliary dilatation. The gallbladder is within normal limits.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There is no evidence of focal renal lesions or hydronephrosis. There is no
perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement throughout. The colon and
rectum are within normal limits. Fluid-filled appendix, measuring up to 8 mm,
with increased mucosal enhancement and surrounding fat stranding (03:51). No
evidence of perforation, abscess. Overall, this is consistent with
uncomplicated appendicitis.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The visualized reproductive organs are unremarkable.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. No atherosclerotic disease
is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
Uncomplicated acute appendicitis.
Gender: M
Race: WHITE - OTHER EUROPEAN
Arrive by WALK IN
Chief complaint: Abd pain
Diagnosed with Unspecified acute appendicitis
temperature: 97.3
heartrate: 80.0
resprate: 18.0
o2sat: 100.0
sbp: 137.0
dbp: 88.0
level of pain: 4
level of acuity: 3.0 | Mr. ___ is a ___ year old male with no significant medical
history who presents with generalized abdominal pain. Routine
bloodwork was drawn and showed no abnormal findings. Given
clinical suspicion for appendicitis, a CT scan of the chest,
abdomen, and pelvis was ordered. No acute pulmonary or
cardiovascular problems were indicated on imaging, but the CT
scan on the abdomen showed acute appendicitis. Patient was made
NPO, counseled, consented and prepared for a laparoscopic
appendectomy that evening. A laparoscopic appendectomy was
performed and the patient recovered uneventfully in the PACU,
then transferred to the floor. On Post op day 1, hospital
course day 2, the patient was started on a clear diet, and his
pain was controlled with combination therapy pain management
which involved minimal narcotics use. Patient tolerated a clear
liquid diet and passed flatus and was advanced to a regular diet
for lunch post op day 1. Patient tolerated a regular diet and
had a bowel movement prior to discharge. He will follow up with
acute care surgical clinic in ___ weeks. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
fever
Major Surgical or Invasive Procedure:
Hepatic bile lake drain placement ___
Subsequent ERCP with CBD stent placement
History of Present Illness:
___ w/ fibrolamellar HCC s/p TACE on ___, dc-ed on ___
who presented to ___ ED with fever, nasuea, headache.
The patient called the hem onc fellow, stated she had a fever
last evening to ___ for which she took advil. This morning, she
reported another fever to 101.5F. Also felt nauseated. She
reported no jaundice, rashes, ___ stools. The fellow
advised her to come to the ED for lab check (LFTs, CBC, CHem)
and to r/o infection with blood cultures.
- In the ED, initial VS were 6 101.7 104 132/73 18 100%.
- Labs were notable for na 131, uptrending LFTs but otherwise
normal chem panel, cbc, lactate, UA and -ve hcg. Blood cultures
sent.
- Patient given tylenol, zofran, oxycodone, ibuprofen and 1L NS.
- Patient was admitted to OMED for further management.
- VS prior to ED 8 100.6 105 124/66 16 97% RA.
The patient was VSS on arrival although was febrile. She
complained of a headache, nausea, says she hasnt had much to
drink other than gingerale, has also had ice cream. Abdominal
pain reported epigastric and in RUQ.
REVIEW OF SYSTEMS: +ve per HPI.
Past Medical History:
PAST ONCOLOGIC HISTORY (updated from last dc summary):
-___: Began experiencing intermittent episodes of
non- radiating, localized mid-epigastric pain associated with
nausea and occasionally emesis when the pain was more severe.
She states the episodes of pain would occur initially on the
order of once every few weeks. However, over the course of the
past year, the intense episodes occur almost daily in the form
of severe pain with n/v; aside from the severe pain, she now
also experiences a constant dull mid-epigastric pain. In
addition to the pain, she has also noted an unintentional forty
pound weight loss since ___ with decreased appetite
and early satiety. She had been experiencing almost nightly
drenching night sweats soaking through her clothes and wetting
mher hair for the past six months in addition to generalized
mfatigue and an infrequent subjective fever (once every month).
-___ medical attention a few times for these symptoms. In
___, she went into walk-in clinics on a few occasions and
was given antiacids or told she had anxiety.
-___: ___ ED because she noted 2 tablespoons
of blood with a bout of emesis. She was discharged from the ED
and placed on pepcid for a month.
-___: Due to a severe bout of abdominal pain and emesis,
she presented to ___. Doppler Ultrasound of the
abdomen showed a large mass of the left lobe of liver extending
to the caudate lobe measuring 8.8 x 5.5 x 7.6 cm, a
well-defined hypoechoic mass posterior to the pancreas measuring
4.0 x 2.5 x 3.6 cm concerning for an enlarged lymph node, and
fatty infiltration of the liver with appropriate Doppler blood
flow in the portal veins with no evidence of splenic
enlargement. A CT Abdomen and Pelvis revealed a large
heterogenous left liver lobe mass measuring 0.5 x 8.1 x 9.4 cm,
a heterogeneously enhancing mass adjacent the head of the
pancreas measuring 3.4 x 3.0 x 4.3 cm, and multiple periportal
lymph nodes measuring up to 2.0 x 1.6 cm. Her labs were
reflective of a WBC of 13.9 with 77.8% PMNs and 10.8%
lymphocytes, a negative urine pregnancy test, an AST/ALT of
670/188, an alkaline phosphatase of 112, and a normal bilirubin.
-Transferred to the ___. CT Chest no evidence of masses or
lymphadenopathy.
-___: ___ liver biopsy which consistent with
fibrolamellar hepatocellular carcinoma. Her AFP was notably not
elevated. She was discharged on ___ with prn dilaudid for
her associated abdominal pain.
-___, her case was presented at liver tumor conference.
After discussion with the multidisciplinary team (surgery,
radiation oncology, and oncology), it was recommended for her to
proceed with surgical excision
-___: Exploratory laparotomy, intraoperative ultrasound,
left hepatic lobectomy, portal lymph node dissection, and
placement of fiducial markers. Course complicated by biloma s/p
___ drainage
**PATH:
-Pancreatic head and portal lymph node #1, resection (2A-2B):
Metastatic hepatocellular carcinoma, fibrolamellar variant in
one lymph node. Residual lymphoid tissue is seen (___).
-Lymph node, right portal vein (3A-3B): One lymph node, no
carcinoma seen (___).
-Lymph node, hepatic artery (4A-4E): Metastatic HCC,
fibrolamellar variant in one lymph node (___). Residual lymphoid
tissue is seen.
-Greatest dimension: 8.6 cm. Additional ___: 5.5 cm. x
3.2 cm. G2: Moderately differentiate. Negative for invasive
carcinoma. Macroscopic Venous (Large Vessel) Invasion: Present
Microscopic (Small Vessel) Invasion: Present Perineural
Invasion: Present
-___: Percutaneous transhepatic cholangiography with
biliary drain placement
-___: CT A/P *Large fluid collection along the left hepatic
lobectomy site, compatible with biloma. *New moderate
intrahepatic biliary ductal dilatation with the etiology
unclear. There are sutures and clips near the site of caliber
change as well as the JP drainage catheter passing this region,
however the etiology is not definitely identified and could be
due to extrinsic compression by the biloma.
-___: cholangiogram and exchange of percutaneous
transhepatic biliary drain placement (now internal-external
drain)
-___: D/Ced from hospital
-___: D/ced after admission for fever; Interventional
Radiology performed a cholangiogram noting a small fluid
collection along the anterior aspect of the hepatectomy site
with the pigtail catheter terminating more posteriorly, where
there was no longer residual fluid; dced on IV abx
-___: Admitted to ___ for Adbl pain with fluid
collection; biliary withdrawn to terminate in the fluid.
-___: Surgery clinic drain removed; placed on Augmentin.
-___: Cholangiogram w/persistent area of stenosis at main
RHD and CBD; balloon dilatation performed with some improvement;
PTBD upsized to ___. Fever s/p procedure and admitted to ___.
-___: Cultures grew E. Coli; txed with Unasyn and switched
to PO Bactrim on discharge.
-___: CT A/P: *Interval decrease in fluid collection
adjacent to the medial portion of the remnant liver. A
percutaneous transhepatic biliary drain is identified in
appropriate position.
*Status post left hepatectomy. No evidence of disease recurrence
within the remaining liver. No evidence of metastatic disease
within the abdomen and pelvis. *Thrombosed portal vein branch
supplying segment IVb, unchanged since prior examination.
-___: Cholangiogram
*Pre-existing 10 ___ internal-external biliary drain in
appropriate position. *Cholangiogram showing brisk flow of
contrast into the duodenum. There was moderate improvement in
the degree of stenosis at the junction of the main right hepatic
duct and common bile duct, although some mild residual narrowing
remains. There was satisfactory forward flow. No dilatation was
performed. *Successful exchange of 10 ___ percutaneous
transhepatic biliary drainage catheter for a 10 ___ Amplatz
anchor drain.
-___: CT Chest-negative; MRI Abdomen-multiple
hyperenhancing lesions maximal 10mm
-___: CT Pelvis and bone scan-no lesions
- ___ underwent subselective Seg VII, VIII lobe TACE
- ___ readmitted with pain, nausea and fevers
PAST MEDICAL HISTORY:
- Stage ___ fibrolamellar hepatocellular carcinoma (T2N1M0)
- L leg fracture
- Nephrolithiasis
- Depression w/ h/o suicide attempt w/ OD x1
Past Surgical History:
- L hepatic lobectomy
- LLE plates/screws for fx and 1 revision procedure
Social History:
___
Family History:
No liver disease or cancer
Physical Exam:
ADMISSION PHYSICAL EXAM:
General: NAD
VITAL SIGNS: 102.2 125/67 108 16 97 ra
HEENT: MMM, no OP lesions, no cervical, supraclavicular, or
axillary adenopathy, no thyromegaly
CV: RR, NL S1S2 no S3S4 MRG
PULM: CTAB
ABD: BS+, soft, mild tenderness in RUQ, no masses or
hepatosplenomegaly
LIMBS: No edema, clubbing, tremors, or asterixis; no inguinal
adenopathy
SKIN: No rashes or skin breakdown
NEURO: Cranial nerves II-XII are within normal limits excluding
visual acuity which was not assessed, no nystagmus; strength is
___ of the proximal and distal upper and lower extremities
DISCHARGE EXAM:
VS 98.1 106/68 71 18 98 RA
HEENT: MMM, no OP lesions, no cervical, supraclavicular, or
axillary adenopathy
CV: RR, NL S1S2 no S3S4 MRG
PULM: CTAB
ABD: BS+, R jp drain in place draining green/clear bile,
nontender abdomen other than at drain insertion site in RUQ, no
distention, no masses.
LIMBS: No edema, clubbing, tremors, or asterixis; no inguinal
adenopathy
SKIN: No rashes or skin breakdown
NEURO: ___, EOMI, face symmetric, moves all ext against
resistance, sensation intact to light touch
Pertinent Results:
ADMISSION LABS:
___ 05:20PM BLOOD ___ PTT-31.5 ___
___ 07:36AM BLOOD Glucose-91 UreaN-4* Creat-0.7 Na-137
K-4.2 Cl-102 HCO3-28 AnGap-11
___ 05:20PM BLOOD ALT-121* AST-122* AlkPhos-210*
TotBili-0.3
___ 07:36AM BLOOD Calcium-8.9 Phos-3.0 Mg-1.9
CT abdomen/pelvis ___:
IMPRESSION:
1. Findings concerning for biliary ischemia including new bile
lakes about the portal vein branches. Superinfection cannot be
excluded by CT.
2. Hypoattenuation of multiple hepatic metastases seen on prior
MRI consistent with post TACE state.
3. Patent portal and hepatic veins. The extrahepatic hepatic
artery is patent.
MRCP ___
IMPRESSION:
1. Ischemic cholangitis with bile lakes in segments VII and VIII
status post TACE. No MRI findings to suggest superinfection.
2. Peripheral enhancement surrounding a 1.3 cm treated lesion in
segment VIII may reflect post treatment change, although a
small developing abscess is not excluded.
3. Overall improvement in diffuse hepatic metastases
particularly in the treated segments, however multiple
persistent enhancing lesions in segments V and VI remain
consistent with viable HCC metastases.
MRCP ___:
IMPRESSION:
Progression of sequela of ischemic cholangiopathy with
increasing size of previously seen the bile lakes. Despite
presence of gas within the lakes, and heterogeneous parenchymal
enhancement, there is no one particular collection which
demonstrates definitive features of infection or different
features from the collections elsewhere. Gas and enhancement
can be accounted for by recent interventions, sphincterotomy,
and vascular insults. Numerous treated and several viable foci
of metastatic disease. Bilateral renal parenchymal edema and
heterogeneous enhancement suggestive of pyelonephritis.
Echo ___ The left atrium is mildly dilated. Left ventricular
wall thickness, cavity size and regional/global systolic
function are normal (LVEF >55%). Doppler parameters are most
consistent with normal left ventricular diastolic function.
Right ventricular chamber size and free wall motion are normal.
The diameters of aorta at the sinus, ascending and arch levels
are normal. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion and no aortic stenosis. Trace
aortic regurgitation is seen. The mitral valve appears
structurally normal with trivial mitral regurgitation. There is
no mitral valve prolapse. The estimated pulmonary artery
systolic pressure is normal. There is a trivial/physiologic
pericardial effusion.
IMPRESSION: No evidence of valvular vegetations. Preserved
biventricular regional/global systolic function. No significant
valvular disease.
Percutaneous Drain ___:
FINDINGS:
1. Limited grayscale ultrasound imaging of the liver re-
demonstrates multiple heterogeneous and hypoechoic areas within
the right lobe of the liver, consistent with areas identified on
the prior MRI.
2. Sinogram of the accessed collection demonstrates filling of
the cavity. No obvious connection to the biliary tree is
identified, however aggressive distension of the cavity was not
performed given known infected nature of the fluid.
3. 8 ___ APDL drainage catheter placed.
4. 12 cc brownish fluid removed and sent for microbiology
evaluation.
IMPRESSION:
Successful placement of 8 ___ drainage catheter into hepatic
collection/cavity.
ERCP ___
The scout film revealed previous surgical clips and biliary
drain in place. The bile duct was deeply cannulated with the
sphincterotome and then with the balloon over the guidewire.
Contrast was injected and there was brisk flow through the
ducts. Contrast extended to the entire biliary tree. The CBD was
8mm in diameter. There were no filling defects. The right
hepatic ducts and all intrahepatic branches were normal. There
was no evidence of bile leak. Given clinical presentation with
biloma with ongoing output from biliary drain, decision was made
to place a CBD stent. A 10cm by ___ plastic stent was placed
successfully in the CBD. Excellent bile and contrast drainage
was seen endoscopically and fluoroscopically. Otherwise normal
ercp to third part of the duodenum
DISCHARGE LABS:
___ 05:30AM BLOOD WBC-8.5 RBC-3.24* Hgb-8.7* Hct-26.3*
MCV-81* MCH-26.9* MCHC-33.1 RDW-14.5 Plt ___
___ 05:30AM BLOOD Glucose-94 UreaN-4* Creat-0.7 Na-139
K-4.1 Cl-103 HCO3-26 AnGap-14
___ 05:30AM BLOOD ALT-29 AST-43* AlkPhos-751* TotBili-0.6
___ 05:30AM BLOOD Calcium-8.5 Phos-4.2 Mg-1.4*
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Citalopram 20 mg PO DAILY
2. Lorazepam 0.5 mg PO Q6H:PRN anxiety
3. Ondansetron 8 mg PO Q8H:PRN nausea
4. MetRONIDAZOLE (FLagyl) 500 mg PO TID
5. Ranitidine 150 mg PO BID
6. Sulfameth/Trimethoprim DS 1 TAB PO BID
7. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN pain
8. Morphine SR (MS ___ 15 mg PO Q8H
9. Docusate Sodium 100 mg PO DAILY
10. Senna 8.6 mg PO DAILY
11. Polyethylene Glycol 17 g PO DAILY:PRN constipation
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Cholangitis
Bacteremia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT abdomen and pelvis with intravenous contrast.
INDICATION: ___ year old woman with fibrolamellar liver CA s/p TACE h/o
abscess now with high fevers and GPC bacteremia pls r/o liver abscess thank
you! // r/o liver abscess/other intra-abd infection, any CBD dilation, thank
you!
TECHNIQUE: MDCT axial images were acquired through abdomen and pelvis
following intravenous contrast administration with split bolus technique.
Coronal and sagittal reformations were performed and reviewed on PACS.
Oral contrast was administered.
DOSE: DLP: 1042.80 mGy-cm (abdomen and pelvis.
IV Contrast: 130 mL Omnipaque
COMPARISON: MRI abdomen ___. CT abdomen ___.
FINDINGS:
LOWER CHEST:
There is bibasilar atelectasis. There is no pleural or pericardial effusion.
Heart size is not enlarged.
Abdomen/pelvis:
Surrounding the portal tracts are irregular branching and lobulated
hypodensities consistent with bile lakes that are new in the interval since
prior MR of ___. At least one air containing structure is seen
consistent with small quantity of pneumobilia within a bile duct in the center
of one such lake (4:20). There are numerous round hypoenhancing foci
throughout the liver consistent with lesions treated with trans arterial chemo
embolization. Some segmental biliary ductal dilation is redemonstrated along
the anterior aspect of the hepatic remnant (4:30), unchanged. There has been
prior left hepatectomy. Portal and hepatic vein branches remain patent. The
extrahepatic portion of the hepatic artery opacifies (4:28). The spleen
measures 13.4 cm in length.
There is no evidence of pancreatic mass or pancreatic ductal dilatation. There
is symmetric renal enhancement and excretion of intravenous contrast. Urinary
bladder is mildly distended without gross abnormality.
There are no dilated loops of bowel. There is no evidence of bowel wall
thickening. There is no intraperitoneal free air or free fluid.
The abdominal aorta has a normal course and caliber. There are no enlarged
inguinal or iliac chain lymph nodes. There is no suspicious osseous lesion.
IMPRESSION:
1. Findings concerning for biliary ischemia including new bile lakes about the
portal vein branches. Superinfection cannot be excluded by CT.
2. Hypoattenuation of multiple hepatic metastases seen on prior MRI consistent
with post TACE state.
3. Patent portal and hepatic veins. The extrahepatic hepatic artery is patent.
NOTIFICATION: Results were discussed with the clinical team caring for the
patient 15 minutes following discovery on ___ via telephone.
Radiology Report
INDICATION: ___ year old woman with RA biliary dilation post TACE // R PTBD
COMPARISON: CT from ___.
TECHNIQUE: OPERATORS: Dr. ___ resident) and Dr. ___
___ radiology attending) performed the procedure. The attending,
Dr. ___ was present and supervising throughout the procedure. Dr.
___ radiologist, personally supervised the trainee during the
key components of the procedure and reviewed and agreed with the trainee's
findings.
ANESTHESIA: General anesthesia was administered by the anesthesiology
department. Please refer to anesthesiology notes for details.
MEDICATIONS: 1 g ceftriaxone
CONTRAST: 65 ml of Optiray contrast.
FLUOROSCOPY TIME AND DOSE: 16.4 min, 3000 cGy-cm2
PROCEDURE:
1. Transabdominal ultrasound.
2. Ultrasound guided right percutaneous transhepatic bile duct access.
3. Right cholangiogram
PROCEDURE DETAILS:
Following the discussion of the risks, benefits, and alternatives to the
procedure, written informed consent was obtained from the patient. The patient
was then brought to the angiography suite and placed supine on the exam table.
A pre-procedure time-out was performed per ___ protocol. The right abdomen
was prepped and draped in the usual sterile fashion.
Multiple passes were made through the liver utilizing a 21 gauge cook needle
under ultrasound and fluoroscopic guidance. Initial images demonstrate a
irregular collection of contrast near segments 7 and 8 of the liver
corresponding to the CT images. Ultrasound was utilized extensively which did
not demonstrate any dilated bile ducts, only normal caliber ducts adjacent to
portal vessels. Eventually, under fluoroscopic guidance, a Cook needle was
advanced into the right posterior biliary system and a right-sided
cholangiogram was performed which demonstrated normal caliber bile ducts and
prompt flow to the CBD and into the small bowel. The right anterior bile duct
was also opacified and was noted to be of normal caliber and coursing through
the area of earlier identified collection. There was no clear communication
with this collection and the traversing bile duct. Given that there was no
dilation or obstruction of the biliary system and prompt flow of contrast
through the common bile duct, as well is no communication with the collections
surrounding the right anterior ducts, the decision was made not to place a
percutaneous drain.
The needles were removed. The patient tolerated the procedure well. There were
no immediate complications.
FINDINGS:
1. Normal caliber intra and extrahepatic bile ducts with prompt drainage
through to the duodenum and no evidence of obstruction.
2. Opacified collection of likely necrotic tissue surrounding the right
anterior ducts, but with no clear communication with the transversing ducts.
IMPRESSION:
Transhepatic cholangiogram performed with results as above.
RECOMMENDATION: MRCP could be performed to evaluate the relation between the
collections demonstrated on the previous CT and the biliary system.
Radiology Report
EXAMINATION: MRI abdomen with and without contrast.
INDICATION: ___ year old woman with liver cancer s/p TACE now with cholangitis
and CT with ?biliary abscesses but attempted drainage unsuccessful, need to
characterize these further. PLEASE ALSO DO WITH CONTRAST TO CHARACTERIZE LIVER
TUMOR // ?biliary abscesses but attempted drainage unsuccessful, need to
characterize these further. PLEASE ALSO DO WITH CONTRAST TO CHARACTERIZE LIVER
TUMOR
TECHNIQUE: Multiplanar T1 and T2 weighted sequences were obtained in a 1.5
Tesla magnet including dynamic 3D imaging performed prior to, during, and
after the uneventful administration 8cc of ___.
COMPARISON: MRI abdomen of ___
FINDINGS:
Minimal atelectasis is present at the lung bases. There are no pleural
effusions.
The liver demonstrates changes of prior left hepatectomy. Multiple serpiginous
areas of fluid signal intensity are present throughout segments VII and VIII
following the course of the intrahepatic bile ducts. This appearance is
characteristic for ischemic cholangitis and corresponds to the segments
treated by recent TACE. There is no peripheral enhancement or loculated gas
to suggest superinfection.
A 1.3 cm lesion at the periphery of segment VIII now demonstrates progressive
peripheral enhancement (1602:49), possibly due to treatment change. Other
previously arterial enhancing lesions in segments VIII and VII are no longer
seen. Numerous lesions persist in segments V and VI ; essentially all of these
display arterial phase hyperenhancement with subsequent washout consistent
with HCC metastases. One lesion at the periphery of segment V is slightly
enlarged, 1.3 cm currently from prior 0.9 cm (1601:84). Other lesions are
smaller or less conspicuous: For example, a prior 0.9 cm lesion at the
inferior margin of segment VI is not measurable on the current study. Two
hyperenhancing foci in segment V, new from the prior exam, are most consistent
with perfusion difference (1601:70).
The spleen, pancreas, adrenal glands, and kidneys have a normal appearance.
Visualized bowel and mesentery are unremarkable. There is no retroperitoneal
or mesenteric lymphadenopathy.
A small volume of free fluid is present in the pelvis.
No concerning osseous lesion is identified.
IMPRESSION:
1. Ischemic cholangitis with bile lakes in segments VII and VIII status post
TACE. No MRI findings to suggest superinfection.
2. Peripheral enhancement surrounding a 1.3 cm treated lesion in segment VIII
may reflect post treatment change, although a small developing abscess is not
excluded.
3. Overall improvement in diffuse hepatic metastases particularly in the
treated segments, however multiple persistent enhancing lesions in segments V
and VI remain consistent with viable HCC metastases.
Radiology Report
EXAMINATION: CHEST PORT. LINE PLACEMENT
INDICATION: ___ year old woman with just got PICC. Evaluate line placement.
TECHNIQUE: Single portable AP view of the chest.
COMPARISON: Chest PA and lateral from ___.
FINDINGS:
The left PICC line tip terminates in the right atrium and should be withdrawn
at least 6.5 cm to be positioned in the lower SVC, if desired. No
pneumothorax. There is minimal right basilar atelectasis. The lungs are
otherwise clear without focal consolidation or large effusions. Heart size,
mediastinal, and hilar contours are normal.
IMPRESSION:
The left PICC line tip terminates in the right atrium and should be withdrawn
at least 6.5 cm to be positioned in the lower SVC, if desired.
NOTIFICATION: The above findings were communicated on the telephone by Dr.
___ to ___ (IV RN) at 16:36 on ___, 2 min after
discovery.
Radiology Report
EXAMINATION: CHEST PORT. LINE PLACEMENT
INDICATION: ___ year old woman with picc adjustment // pls eval picc
placement Contact name: white, ___: ___
TECHNIQUE: Single frontal view of the chest
COMPARISON: Study performed 2 hours earlier
IMPRESSION:
Right PICC tip is in thecavoatrial junction. No other interval change
Radiology Report
EXAMINATION: MRI of the abdomen with and without contrast
INDICATION: ___ year old woman with Fibrolamellar HCC post TACE, persistent
fevers worsening LFTs // eval for coalescing bile lakes from worsening
ischemic cholangitis vs abscess formation
TECHNIQUE: Multiplanar MRI of the abdomen is obtained at 1.5 Tesla per the
liver mass protocol. T1 and T2 weighted sequences are acquired both pre and
post administration of 8 mL of gadavist.
COMPARISON: Multiple prior abdominal CTs and MRIs most recently dating ___
FINDINGS:
Hepatic morphology is consistent with provided history of a prior left
hepatectomy. There has been a significant interval change since the most
recent examination 3 days previously. The previously-seen bile lakes, denoted
by serpiginous areas of fluid intensity along the course of the intrahepatic
bile ducts are re-demonstrated. There appear to be at least three discretely
separate fluid collections seen centrally originating adjacent to the
resection margin. As these extend superiorly into segments VII and VIII, the
middle fluid collection expands and bifurcates (5:14). This component has
significantly increased in size from a 1.5 x 2.4 cm nonenhancing component to
a 7.7 x 3.9 cm region of nonenhancement (903:30). The new areas of fluid
signal correlate with the previously seen areas of parenchymal heterogeneity
of signal and enhancement, presumably representing progressive liquefaction of
ischemic parenchyma. While parts of this segment VIII abnormality demonstrate
T2 hyperintensity of fluid (4:11), more peripheral areas are edematous and
nonenhancing, but less T2 hyperintense (4:13).
Each of these fluid pockets is variably T2 hyperintense and T1 hypointense and
nonenhancing. There are punctate foci of susceptibility artifact within the
bile lakes, consistent with gas. Despite this finding, there is no identified
region of restricted diffusion and most have no surrounding rim of
hyperenhancement to suggest suprainfection. This gas is likely on the basis
of prior sphincterotomy given gas within the central bile duct, as well as
prior attempted drainage. Bile lakes adjacent to the resection margin which
were previously present and are unchanged in size do demonstrate a thin rim of
hyperenhancement (904:54), particularly on delayed sequences. This likely
represents maturation and organization rather than evidence of suprainfection.
The extrahepatic bile duct appears in tact. The central intrahepatic biliary
tree adjacent to the resection margin are notable for thickened,
hyperenhancing walls (901:64). This is slightly more apparent on the prior
examination. This may simply represent ischemic but intact bile duct walls.
Cholangitis is not excluded.
The portal venous system remains patent. However, the posterior branches are
somewhat attenuated, likely due to mass effect from the enlarging bile lakes.
This results in heterogeneous parenchymal enhancement, seen particularly on
the arterial phase. The hepatic arteries are variable in their degree of
enhancement as they course through the bile lakes.
There are numerous foci of subtle T2 hypointensity, central nonenhancement and
a rim of hyperenhancement throughout the liver. These appear to represent
treated, nonviable metastases, correlating with previously artery
hyperenhancing lesions. Several persistently arterially hyperenhancing and
nodules are noted within segments V and VI. Some of these appear to have
slightly increased in size by 1-2 mm (901:110).
The spleen is relatively normal in size with maximum diameter of 13 cm. There
is no evidence of chronic portal hypertension. Pancreas and adrenal glands
are unremarkable.
There is bilateral diffuse renal abnormality. The parenchyma is edematous on
T2 weighted sequences, heterogeneous on DWI and enhances in a striated pattern
(903:114). The appearance is highly suggestive of pyelonephritis, likely
hematologically distributed.
No ascites is currently appreciated. There is some subcutaneous edema noted,
as well as a trace right pleural effusion.
IMPRESSION:
Progression of sequela of ischemic cholangiopathy with increasing size of
previously seen the bile lakes. Despite presence of gas within the lakes, and
heterogeneous parenchymal enhancement, there is no one particular collection
which demonstrates definitive features of infection or different features from
the collections elsewhere. Gas and enhancement can be accounted for by recent
interventions, sphincterotomy, and vascular insults.
Numerous treated and several viable foci of metastatic disease.
Bilateral renal parenchymal edema and heterogeneous enhancement suggestive of
pyelonephritis.
NOTIFICATION: Findings were communicated via phone by Dr ___ to Dr ___
at approximately 9:30 am on ___.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ year old woman with fevers post TACE // please eval
size/echogenicity of bile lakes/hepatic collections, in preparation for
possible aspiration or drain placement by ___
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: MRI ___.
FINDINGS:
LIVER: The patient is status post left hepatectomy. A complex heterogeneous
area with air is seen in the right hepatic lobe as noted on the prior MRI. On
today's ultrasound, it is not clear that all portions of the collection
communicate with each other although they are communicating on the prior MRI.
___ components of the collection has minimal through transmission, but no
distinct fluid component is identified. Main portal vein is patent with
hepatopetal flow. There is no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. Pneumobilia is
present. The CBD measures 8 mm.
GALLBLADDER: The gallbladder is absent.
PANCREAS: The head of the pancreas is within normal limits. The body and tail
of the pancreas are not visualized due to the presence of gas.
SPLEEN: Normal echogenicity, measuring 12.7 cm.
KIDNEYS: Limited views of the right kidney showed no hydronephrosis.
RETROPERITONEUM: Visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
Heterogenous complex intrahepatic collection, better evaluated on the prior
MRI. No distinct fluid component is seen within it and areas still appears
solid on ultrasound. Drainability is uncertain at this time. Short-term
followup is suggested.
RECOMMENDATION(S): The findings were discussed by Dr. ___ with
Dr. ___ (surgery) in person on ___ at 11:00 a.m., 5 minutes
after discovery of the findings. Aditionally, Dr. ___ the
findings with Dr. ___ ___ Fellow) by phone at 1pm on ___.
Radiology Report
INDICATION: ___ year old woman with fibrolamellar ___ s/p TACE with presence
of multiple enlarging bile lakes continuing to spike fevers. // Aspiration of
bile lake/collection
COMPARISON: MRI ___, ultrasound ___
TECHNIQUE: OPERATORS: Dr. ___ radiology attending)
performed the procedure assisted by Dr. ___ radiology
fellow) and, Dr. ___ resident) . The attending, Dr. ___ was
present and supervising throughout the procedure. Dr. ___
radiologist, personally performed all the key components of the procedure and
reviewed and agreed with the trainee's findings.
ANESTHESIA: Moderate sedation was provided by administrating divided doses of
150mcg of fentanyl and 3 mg of midazolam throughout the total intra-service
time of 20 during which the patient's hemodynamic parameters were continuously
monitored by an independent trained radiology nurse. 1% lidocaine was injected
in the skin and subcutaneous tissues overlying the access site.
MEDICATIONS: Fentanyl, midazolam
CONTRAST: 0 ml of Optiray contrast.
FLUOROSCOPY TIME AND DOSE: None
PROCEDURE:
1. Ultrasound-guided needle aspiration from hepatic collection.
PROCEDURE DETAILS:
Following the discussion of the risks, benefits and alternatives to the
procedure, written informed consent was obtained from the patient. The patient
was then brought to the angiography suite and placed supine on the exam table.
A pre-procedure time-out was performed per ___ protocol.
A preliminary right upper quadrant ultrasound again demonstrated multiple
complex hypoechoic collections in the right lobe with internal septations and
tiny echogenic foci. A superficial collection in the right lobe with posterior
acoustic shadowing was targeted or aspiration. Under direct ultrasound
guidance, a 21 gauge needle was advanced into the collection. 8 cc of turbid
brown fluid were aspirated. The specimen was sent to the lab for Gram stain
and culture.
FINDINGS:
1. Multiple complex collections in the right lobe of the liver with internal
septations and tiny echogenic foci compatible with air. The targeted
collection had increased posterior acoustic through transmission suggestive of
liquification.
2. 8 cc of turbid brown fluid aspirated from one of these collections.
IMPRESSION:
Successful fine needle aspiration from one of several right hepatic lobe
complex collections.
Radiology Report
INDICATION: ___ female with fibrolamellar hepatocellular carcinoma
status post TACE complicated by development of biliary lakes. Request
aspiration of biliary leak collections.
COMPARISON: Abscess aspiration from ___, liver ultrasound from ___, and MRI of the abdomen from ___.
TECHNIQUE: OPERATORS: Dr. ___ radiology fellow) and Dr.
___ radiology attending) performed the procedure. The
attending, Dr. ___ was present and supervising throughout the procedure.
Dr. ___ radiologist, personally supervised the trainee during
the key components of the procedure and reviewed and agreed with the trainee's
findings.
ANESTHESIA: Moderate sedation was provided by administrating divided doses of
250mcg of fentanyl and 5 mg of midazolam throughout the total intra-service
time of 53 minutes during which the patient's hemodynamic parameters were
continuously monitored by an independent trained radiology nurse. 1% lidocaine
was injected in the skin and subcutaneous tissues overlying the access site.
MEDICATIONS: Fentanyl, midazolam.
CONTRAST: 20 ml of Optiray contrast.
FLUOROSCOPY TIME AND DOSE: 8.5 minutes, 513 cGy-cm2
PROCEDURE:
1. Transabdominal ultrasound.
2. Ultrasound-guided access into the mive echogenicity hepatic collection.
3. Placement of 8 ___ drainage catheter into the hepatic collection.
The procedure, risks, benefits and alternatives were discussed with the
patient and written informed consent was obtained. The abdomen was cleaned and
draped in standard sterile fashion. A pre-procedure time-out was performed as
per ___ protocol.
Limited transabdominal ultrasound of the right upper quadrant was performed,
Re demonstrating multiple heterogeneous and hyperechoic areas in the right
lobe of the liver, towards the liver dome.
Under ultrasound guidance, an entrance site was selected from a right
intercostal approach. 1% lidocaine was instilled for local anesthesia. Under
direct ultrasound guidance, a 21 gauge Cook needle was advanced into the
dominant appearing hepatic collection. Upon return of small amount of brownish
fluid, a Nitinol wire was advanced into the collection. A small skin incision
was made. The needle was exchanged for an Accustick sheath, which was advanced
over the wire and into the collection. The inner stiffener and dilator were
removed. A ___ wire was advanced through the Accustick sheath and passed
several times back and forth through the collection in attempts to disrupt any
loculations or septations. A small injection with dilute contrast was then
performed to opacify the hepatic collection.
___ wire was advanced through the Accustick sheath and coiled within
the collection. The Accustick sheath was then removed and an 8 ___ APDL
drainage catheter was advanced over the wire and into appropriate position.
Positioning was confirmed with injection of dilute contrast. Approximately 12
cc of brownish opaque fluid was obtained and sent to microbiology.
The pigtail was formed and locked with securing suture and the catheter was
attached to a JP bulb for drainage. The catheter was secured to the skin with
0-silk suture and a Stat Lock device. Sterile dressings were applied.
The patient tolerated the procedure well without any immediate post-procedure
complications.
FINDINGS:
1. Limited grayscale ultrasound imaging of the liver re- demonstrates multiple
heterogeneous and hypoechoic areas within the right lobe of the liver,
consistent with areas identified on the prior MRI.
2. Sinogram of the accessed collection demonstrates filling of the cavity. No
obvious connection to the biliary tree is identified, however aggressive
distension of the cavity was not performed given known infected nature of the
fluid.
3. 8 ___ APDL drainage catheter placed.
4. 12 cc brownish fluid removed and sent for microbiology evaluation.
IMPRESSION:
Successful placement of 8 ___ drainage catheter into hepatic
collection/cavity.
RECOMMENDATION: Monitor output.
When the patient is more clinically stable a contrast study through the
catheter may be performed to assess for a communication with the biliary tree.
Radiology Report
EXAMINATION: Fistulagram
INDICATION: History of fibrolamellar HCC status post TACE complicated by
fluid collection status post percutaneous drain placement. Question of
possible communication with the biliary tree.
TECHNIQUE: Existing right abdominal percutaneous drainage catheter was gently
injected with 50 cc Optiray contrast under continuous fluoroscopy
DOSE: Fluoroscopy time: 60 seconds
COMPARISON: Abscess drainage procedure ___. Abdominal ultrasound
___. Abdominal MR ___.
FINDINGS:
After gentle injection of Optiray contrast, opacification of the collection
cavity is noted which appears to communicate with the common bile duct with
prompt flow of the contrast material through the existing CBD stent into the
duodenum. No opacification of the intrahepatic biliary tree.
IMPRESSION:
Fistulization of the known fluid collection with the common bile duct. CBD
stent appears patent with prompt outflow of injected contrast into the
duodenum. No back filling of the intrahepatic biliary tree.
Radiology Report
EXAMINATION: CT ABD WANDW/O C
INDICATION: ___ year old woman with s/p tace, liver CA, here with infected
bile lakes/liver abscess now with diaphoresis, leukocytosis, elevated alk phos
// please do MULTIPHASIC CT OF THE LIVER (per ___ request) eval for
abscess/collections/bile lakes.
TECHNIQUE: Helical CT acquisition was performed during multiple phases after
the administration of nonionic IV contrast. Oral contrast was also
administered. Multiplanar reformats were obtained.
DOSE: 705 mGy*cm.
COMPARISON: Multiple priors including fistulogram ___, MRI ___
FINDINGS:
Small right pleural effusion with passive atelectasis. Air bronchograms are
present within the atelectatic right lower lobe, pneumonia is difficult to
exclude.
Post insertion of percutaneous pigtail catheter into the largest heterogenous
hepatic dome biliary collection. Injected contrast, likely remaining from the
prior fistulogram, is present within the collections and communicating bile
lakes. Plastic biliary stent is present within the CBD. Multiple other
hypodense collections are present, not containing injected contrast, largest 5
x 1.8 cm, prior 5.1 x 2.5 cm. Moderate intrahepatic ductal dilatation is
otherwise present. Postoperative changes reflect fibrolamellar HCC resection.
There is suspected thrombosis of the peripheral anterior portal venous
branches, without well-defined portal veins supplying the superior liver and
associated transient perfusion difference. This is slightly more pronounced
than prior study, possibly due to technique.
Previously demonstrated foci of metastatic disease are less well appreciated,
the largest measuring 1.5 x 1 cm (4, 50) within the subcapsular aspect of
segment VI.
Unremarkable pancreas without main ductal dilatation. Splenomegaly. Normal
adrenals.
No nephrolithiasis or hydronephrosis. No concerning renal mass. Slightly
mottled postcontrast appearance of the renal cortex is noted bilaterally.
Ingested material within stomach. Stool and contrast within colon. No small
bowel dilation.
Normal caliber abdominal aorta. Patent celiac trunk and SMA. Single bilateral
renal arteries. 1.2 cm left periaortic lymph node is noted, in addition to 1.2
cm right pericardial lymph node, slightly larger than prior. Probable
partially visualized anterior subcutaneous fat injection granuloma.
No suspicious osseous lesions.
IMPRESSION:
1. The largest bile lake at the hepatic dome contains indwelling pigtail
catheter and contrast from recent percutaneous contrast injection. Other
smaller bile lakes are present, largest 5 x 1.8 cm within segment VII,
slightly decreased in size from prior MRI, possibly due to drainage and or
communication with biliary system. Otherwise moderate intrahepatic ductal
dilatation appears grossly simple.
2. Previously demonstrated foci of metastatic disease are less conspicuous,
likely due to different imaging modality, as the prior examination was
performed with MRI. The largest measures 1.5 x 1 cm (4, 50) within the
subcapsular aspect of segment VI.
3. Plastic CBD stent appropriately positioned.
4. Heterogenous renal cortical enhancement is again noted, possibly secondary
to renal edema or pyelonephritis.
5. Increased conspicuity of enlarged retroperitoneal and pericardial lymph
nodes as noted above.
Radiology Report
INDICATION: ___ year old woman with fibrolamellar Ca s/p TACE. S/p abscess
drain placement with communication to biliary tree. // Sinogram/cholangiogram
+/- tube upsize/exchange.
COMPARISON: Sinogram from ___ and CT of the abdomen and pelvis
from ___.
TECHNIQUE: OPERATORS: Dr. ___ radiology fellow) and Dr.
___ radiology attending) performed the procedure. The
attending, Dr. ___ was present and supervising throughout the procedure.
Dr. ___ radiologist, personally supervised the trainee during
the key components of the procedure and reviewed and agreed with the trainee's
findings.
ANESTHESIA: Moderate sedation was provided by administrating divided doses of
200mcg of fentanyl and 3 mg of midazolam throughout the total intra-service
time of 25 min during which the patient's hemodynamic parameters were
continuously monitored by an independent trained radiology nurse. 1% lidocaine
was injected in the skin and subcutaneous tissues overlying the access site.
MEDICATIONS: Fentanyl, midazolam, ceftriaxone.
CONTRAST: 15 ml of Optiray contrast.
FLUOROSCOPY TIME AND DOSE: 11.5 min, 694 cGy-cm2
PROCEDURE:
1. Sinogram through existing biliary drainage catheter.
2. Upsize of 8 ___ drain to 10 ___ modified APDL catheter.
PROCEDURE DETAILS: Following the discussion of the risks, benefits and
alternatives to the procedure, written informed consent was obtained from the
patient. The patient was then brought to the angiography suite and placed
supine on the exam table. A pre-procedure time-out was performed per ___
protocol. The right abdomen was prepped and draped in the usual sterile
fashion.
Initial scout images showed biliary drain in the appropriate position. The
right tube was injected with dilute contrast. The images were stored on PACS.
Following the subcutaneous injection of 1% lidocaine and instillation of
lidocaine jelly into the skin site, the right catheter was cut and ___
wire was advanced through the catheter into the hepatic cavity. Following
dilatation with a 10 ___ dilator, a new ___ modified (additional side hole
cut) APDL catheter was advanced over the wire and into the hepatic
collection/cavity. Positioning was confirmed with dilute contrast injection.
The wire and inner stiffener were then removed, the catheter was flushed, the
loop was formed, the catheter was attached to a bag and sterile dressings were
applied.
The patient tolerated the procedure well and there were no immediate
post-procedure complications.
FINDINGS:
1. Sinogram demonstrates complex cavity, not significantly changed in size
compared to the prior exam. No biliary communication was identified, as seen
on the prior sinogram from ___.
2. Upsize with placement of a 10 ___ modified APDL catheter into the
hepatic cavity.
IMPRESSION:
Successful exchange/upsize of existing ___ drainage catheter with new ___
modified APDL catheter.
RECOMMENDATION: Continued monitoring of output from the drainage catheter .
Gender: F
Race: HISPANIC/LATINO - PUERTO RICAN
Arrive by WALK IN
Chief complaint: FEVER POST PROCEDURE
Diagnosed with FEVER, UNSPECIFIED
temperature: 101.7
heartrate: 104.0
resprate: 18.0
o2sat: 100.0
sbp: 132.0
dbp: 73.0
level of pain: 6
level of acuity: 3.0 | ___ with fibrolammelar HCC s/p left hepatectomy who
underwent subselective Seg VII, VIII lobe TACE on ___
re-admitted post-procedure
with fevers found to have Enterococcus bacteremia and bile lakes
in the liver superinfected with enterococcus and ___.
# Ischemic cholangitis with superinfected bile lakes: ___
recent TACE ___. MRCP ___ showing ischemic cholangitis with
bile lakes in segments VII and VIII, w/ persistent fevers.
Reimaging initially didn't show any drainable collection, but
finally re-attempted aspiration of largest collection ___ with
only small amt drained. That aspiration grew enterococcus and
___ albicans so perc drain was placed ___. Initially this
put out brown fluid but then started putting out green bile
suggesting the collected infected area was now communicating
with the biliary tree. She underwent ERCP ___ with CBD stent
placement (has had prior sphincterotomy and ERCP) in order to
open the CBD in attempt to facilitate internal drainage rather
than drainage of bile out of the external tube. She will monitor
drain outpt daily as outpatient and report to ___, they will
schedule cholangiogram or drain exchange or whatever procedure
deemed necessary.
# Enterococcus faecalis Bacteremia w/ Sepsis: sepsis physiology
on admission but this resolved quickly with antibiotics though
her fevers were persistent initially. Culture from ___ and ___
(blood) grew enterococcus but no positive blood cultures
subsequently. Drain cultures from ___ and ___ grew enterococcus
and ___. Bacteremia was felt to be ___ translocation post
procedure that was temporarily suppressed by post procedure
antibiotics, combined with superinfection of newly noted bile
lakes/ischemic cholangitis (as above). last true fever was ___.
Initially she was treated with vanc zosyn but she developed ___
suspicious for AIN so zosyn was DCd in favor of cipro/flagyl
(vanc continued) then subsequently narrowed to dapto/fluc (for
finding of ___ on ___. Picc had been placed ___. It was
felt that absent persistent blood cultures or temps, likelihood
of endocarditis low, TTE negative also. Plan is for ___ weeks IV
antibiotics with start date ___ the day that the biliary drain
went in. Pt will f/u with ___ clinic. Per transplant
surgery, it is important that she have a cholangiogram via the
external drain prior to pulling the drain.
# Abdominal pain - present prior to TACE and worsened after the
TACE but really became a major issue ___ after drain placement.
Prior to this she was on MS contin 15mg TID with only occasional
___ po dilaudid use and pain was not an issue. Drain placed
and likely irritating intercostal nerves. This was quite painful
for her and she required a dilaudid PCA using over 20mg IV
dilaudid in the first day after the drain was placed. PCA was
uptitrated and then able to be discontinued finally on ___ at
which point MS contin and PO dilaudid were resumed. At the time
of discharge she was on a regimen of ms contin 45/45/30 and will
down titrate as outpatient. Sedation was also an issue and
ritalin 5mg BID was started with some good effect pt wished to
continue this. Lidocaine patch also used for pain locally.
___ - Baseline Cr 0.6, elevated to 1.3 ___, also renal edema
on MR. ___ to 1.1 post hydration and off vanco but not
resolving and developed WBC casts. Per renal, WBC casts on
microscopy is c/f AIN which in her case was felt to be likely
zosyn-induced. Creatinine trended downt o 1.0 and remained there
throughout the subsequent course of her hospitalization. Zosyn
was changed to cipro flagyl because of this concern and
ultimately changed to dapto as above.
#GERD - started on ranitidine for 30 days post TACE but this was
DCd on ___ as it had been over 30 days since the tace. prn
Maalox, Tums
# Nausea: likely from recent tace procedure and underlying
disease and liver involvement of infection. Also worsened in AM
after taking morning meds. Compazine was used with good effect.
She also has prn zofran.
#chronic pain - ___ liver tumor burden. Started on MS contin
last admission, dilaudid prn. Increased as above
#Anemia - stable. likely combo ___ and ACD, no signs bleeding.
# HCC: s/p TACE w/ good improvement in treated hepatic mets but
persistent segment V and VI lesions . Will follow with Dr
___ as outpatient re future plan
# Anxiety/Depression: stable. We continued home ativan,
citalopram
# Malnutrition: poor PO since TACE, albumin low, requested
nutrition consult for best prot supplement. We continued Boost
BOWEL REGIMEN: continued senna/colase/miralax |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
Lipitor
Attending: ___
Chief Complaint:
L sided weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a ___ PMHx HTN, HLD, pre-DM, OSA/COPD, prior
tobacco use and obesity who presents with left hand and face
weakness.
For the past month, pt has had URI symptoms. He has had
intermittent productive cough with green and yellow sputum,
nasal
congestion, and rhinorrhea. He was hospitalized at ___ for these symptoms in early ___ and
he was diagnosed with acute bronchitis and given nebulizers and
azithromycin. Since discharge, he continued to have these
symptoms which waxed and waned.
He saw his PCP ___ and, at that time, also describes
intermittent room spinning sensation and left eyelid drooping
(lasting ___ in the AM, subtle L ptosis observed on PCP ___ so
an MRI brain +/- and MRA ordered. He did not have any weakness,
diplopia, dysarthria, or swallowing difficulties. His MRI showed
small vessel ischemic changes and L ICA stenosis. Carotid
ultrasound then revealed severe (70-79%) stenosis of the
left internal carotid artery. He was then referred to vascular
surgery.
On the day of presentation, the vascular surgery office called
to
schedule an appt. During their conversation, pt stated that he
felt weak in his left hand and had been dropping things and
therefore pt was referred to the ED.
At the time of my assessment, pt reports that he has been weak
in
his left hand for several days, starting after his MRI. He first
noticed this when he had difficulty holding onto his fork and
dropped his fork while eating. He also had difficulty squeezing
his denture cream. He feels these symptoms were sudden in onset
and have remained stable since onset. He also has noticed on the
day of presentation that his left lower face was drooping but he
does not know exactly when this started.
Of note, before his MRI, he reports noticing intermittent
paresthesias in his left hand which continue. He walks with a
cane (over last ___ years) and does not report a change in his
gait
or recent falls. He also continues to have an intermittent room
spinning sensation accompanied by nausea. He denies any
diplopia.
Past Medical History:
Mixed sensorimotor polyneuropathy and polyradiculopathy due to
lumbar spondylosis
DEPRESSION
PRE-DM
GOUT
HYPERLIPIDEMIA
HYPERTENSION
LOW BACK PAIN
OBESITY
OSTEOPOROSIS
SLEEP APNEA
ASCENDING THORACIC AORTIC ANEURYSM
Social History:
Marital status: Married
Tobacco use: Former smoker
Tobacco Use 1ppd x ___ , quit ___ years ago
Occasional alcohol. No illicit substances. Retired ___/multiple jobs.
- Modified Rankin Scale:
[X] 0: No symptoms
[] 1: No significant disability - able to carry out all usual
activities despite some symptoms
[] 2: Slight disability: able to look after own affairs without
assistance but unable to carry out all previous activities
[] 3: Moderate disability: requires some help but able to walk
unassisted
[] 4: Moderately severe disability: unable to attend to own
bodily needs without assistance and unable to walk unassisted
[] 5: Severe disability: requires constant nursing care and
attention, bedridden, incontinent
[] 6: Dead
Family History:
Brother ___ CIRRHOSIS
BREAST CANCER
Sister DIABETES MELLITUS
Physical Exam:
ADMISSION:
General: NAD, resting in bed
HEENT: NCAT, no oropharyngeal lesions, moist mucous membranes,
sclerae anicteric
Neck: Supple
___: RRR
Pulmonary: CTAB
Abdomen: Soft, NT, ND
Extremities: Warm, no edema
Skin: No rashes or lesions
Neurologic Examination:
- Mental Status - Awake, alert, oriented to person, place and
time. Attention to examiner easily maintained. Recalls a
coherent
history. Speech is fluent with full sentences, intact
repetition,
and intact verbal comprehension. Content of speech demonstrates
intact naming (high and low frequency) and no paraphasias.
Normal
prosody. No evidence of hemineglect. No left-right agnosia.
- Cranial Nerves - PERRL 3->2 brisk. VF full to finger wiggling.
EOMI, no nystagmus. ?subtle L eyelid ptosis. On upgaze x30s, no
worsening ptosis or diplopia. V1-V3 without deficits to light
touch bilaterally. L NLFF, forehead raise intact bilaterally.
Eyelid closure intact B/L. Hearing intact to finger rub
bilaterally. No dysarthria. Palate elevation symmetric.
Trapezius
strength ___ bilaterally. Tongue midline.
- Motor - Normal bulk and tone. +downward drift on L. No tremor
or asterixis. Neck flexion/extension ___. No fatiguable weakness
in strong muscles on R.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 4+ ___ ___ 4+ 5 4+ 5 5 4+
R 5 ___ ___ 5 5 5 5 5 5
- Sensory - No deficits to light touch bilaterally, although pt
has difficultly with this aspect of the exam. Proprioception
intact at the fingers and great toe bilaterally. Cortical
sensory
testing intact in left hand.
-DTRs:
Bi Tri ___ Pat Ach
L 1 1 1 1 0
R 1 1 1 1 0
Plantar response flexor bilaterally.
- Coordination - No dysmetria with finger to nose testing
bilaterally. Good speed and intact cadence with rapid
alternating
movements.
- Gait - Deferred.
DISCHARGE PHYSICAL EXAM:
Unchanged from admission although motor exam of LUE/LLE shows
more giveway than true weakness
Pertinent Results:
___ 07:50AM BLOOD WBC-7.6 RBC-4.98 Hgb-15.1 Hct-47.2 MCV-95
MCH-30.3 MCHC-32.0 RDW-12.4 RDWSD-42.5 Plt ___
___ 11:30AM BLOOD WBC-7.8 RBC-4.74 Hgb-14.5 Hct-44.1 MCV-93
MCH-30.6 MCHC-32.9 RDW-12.5 RDWSD-43.4 Plt ___
___ 07:50AM BLOOD Glucose-110* UreaN-18 Creat-1.0 Na-142
K-4.4 Cl-104 HCO3-23 AnGap-19
___ 11:30AM BLOOD Glucose-192* UreaN-19 Creat-1.0 Na-135
K-6.8* Cl-101 HCO3-21* AnGap-20
___ 11:30AM BLOOD ALT-20 AST-45* AlkPhos-47 TotBili-0.5
___ 11:30AM BLOOD cTropnT-0.01
___ 07:50AM BLOOD Calcium-9.9 Phos-3.3 Mg-2.3 Cholest-172
___ 11:30AM BLOOD Albumin-4.0 Calcium-9.3 Phos-2.7 Mg-2.2
___ 07:50AM BLOOD %HbA1c-6.7* eAG-146*
___ 07:50AM BLOOD Triglyc-133 HDL-55 CHOL/HD-3.1 LDLcalc-90
___ 11:30AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-POS* Barbitr-NEG Tricycl-NEG
___ H&N
1. Periapical lucency surrounding what appears to be a residual
fragment of the left maxillary lateral incisor, compatible with
periodontal disease. Formal dental evaluation is advised.
2. Thyroid nodule. No follow up recommended.
___ Head w/o
1. Study is mildly degraded by motion.
2. No acute intracranial abnormality including hemorrhage or
infarct.
3. Extensive paranasal sinus disease concerning for acute
sinusitis, as
described.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 10 mg PO DAILY
2. Gabapentin 300 mg PO QHS
3. Oxybutynin 5 mg PO QHS
4. Benzonatate 100 mg PO TID:PRN Cough
5. Diazepam 5 mg PO QHS
6. Metoprolol Succinate XL 25 mg PO DAILY
7. Ipratropium Bromide Neb 2 NEB IH Q8H
8. Pravastatin 40 mg PO QPM
9. Ascorbic Acid ___ mg PO DAILY
10. Aspirin 81 mg PO DAILY
11. Vitamin B Complex 1 CAP PO DAILY
12. Vitamin E 400 UNIT PO DAILY
13. HYDROcodone-Acetaminophen (5mg-325mg) 1 TAB PO Q8H:PRN Pain
- Moderate
14. Fluticasone Propionate 110mcg 2 PUFF IH BID
15. albuterol sulfate 2.5 mg /3 mL (0.083 %) inhalation
DAILY:PRN
Discharge Medications:
1. Rosuvastatin Calcium 40 mg PO QPM
RX *rosuvastatin 40 mg 1 tablet(s) by mouth nightly Disp #*30
Tablet Refills:*3
2. albuterol sulfate 2.5 mg /3 mL (0.083 %) inhalation
DAILY:PRN
3. Ascorbic Acid ___ mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Benzonatate 100 mg PO TID:PRN Cough
6. Diazepam 5 mg PO QHS
7. Fluticasone Propionate 110mcg 2 PUFF IH BID
8. Gabapentin 300 mg PO QHS
9. HYDROcodone-Acetaminophen (5mg-325mg) 1 TAB PO Q8H:PRN Pain
- Moderate
10. Ipratropium Bromide Neb 2 NEB IH Q8H
11. Lisinopril 10 mg PO DAILY
12. Metoprolol Succinate XL 25 mg PO DAILY
13. Oxybutynin 5 mg PO QHS
14. Vitamin B Complex 1 CAP PO DAILY
15. Vitamin E 400 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Left sided weakness
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ with left sided weakness, cough // Pneumonia or other mass
TECHNIQUE: AP view of the chest.
COMPARISON: ___.
FINDINGS:
There is streaky left basilar opacity. Elsewhere, lungs are clear.
Cardiomediastinal silhouette is within normal limits. No acute osseous
abnormalities.
IMPRESSION:
Streaky left basilar opacity which is most likely atelectasis. Possibility of
infection is difficult to exclude.
Radiology Report
EXAMINATION: CTA HEAD AND CTA NECK Q16 CT NECK
INDICATION: ___ man with left-sided weakness with known carotid
stenosis. Evaluate for infarct, hemorrhage or vascular stenosis.
TECHNIQUE: Contiguous MDCT axial images were obtained through the brain
without contrast material. Subsequently, helically acquired rapid axial
imaging was performed from the aortic arch through the brain during the
infusion of 70 mL of Omnipaque intravenous contrast material.
Three-dimensional angiographic volume rendered, curved reformatted and
segmented images were generated on a dedicated workstation. This report is
based on interpretation of all of these images.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 6.4 s, 16.0 cm; CTDIvol = 56.1 mGy (Head) DLP =
897.1 mGy-cm.
2) Stationary Acquisition 6.0 s, 0.5 cm; CTDIvol = 130.7 mGy (Head) DLP =
65.3 mGy-cm.
3) Spiral Acquisition 5.2 s, 41.2 cm; CTDIvol = 31.9 mGy (Head) DLP =
1,314.6 mGy-cm.
Total DLP (Head) = 2,277 mGy-cm.
COMPARISON: ___, outside hospital noncontrast head CT.
___, contrast head MRI and MRA.
FINDINGS:
CT HEAD WITHOUT CONTRAST:
There is no evidence of infarction, hemorrhage, edema, or mass. The
ventricles and sulci are normal in size and configuration. Subtle areas of
periventricular and subcortical white matter hypodensity are in a
configuration most suggestive of chronic small vessel ischemic disease.
There is mild to moderate bilateral frontal sinus mucosal thickening, near
complete opacification of the bilateral ethmoid air cells and right sphenoid
sinus, mild background polypoid mucosal wall thickening of the bilateral
maxillary sinuses and left sphenoid sinus, as well as aerosolized fluid in the
right maxillary sinus. Periapical lucency is seen surrounding what appears to
be a remnant fragment of the left maxillary lateral incisor with erosion of
the anterior cortex (___). The mastoid air cells, and middle ear cavities
are clear. The visualized portion of the orbits are unremarkable.
CTA HEAD:
There is variant partial fetal type origin of the left posterior cerebral
artery. The left A1 segment of the ACA is hypoplastic with apparent common
origin of the bilateral A2 segments are from the right A1, a normal variant.
There is trace atherosclerotic calcification at the right ICA terminus without
significant narrowing. The vessels of the circle of ___ and their
principal intracranial branches otherwise appear patent without significant
stenosis, occlusion, or aneurysm formation. The dural venous sinuses are
patent.
CTA NECK:
There is moderate calcified and noncalcified atherosclerotic plaque of the
visualized aortic arch. Minimal left vertebral artery origin nonocclusive
narrowing is noted (see 650:16). There is mild atherosclerotic calcification
at the origin of the left subclavian artery without significant narrowing.
There is a 3 vessel aortic arch. There is severe left and mild-to-moderate
right calcified and noncalcified atherosclerotic plaque at the carotid
bifurcations. This produces 75% stenosis of the left internal carotid artery
and 10% stenosis the right internal carotid artery by NASCET criteria. The
carotid and vertebral arteries and their major branches are otherwise patent
with no evidence of additional stenosis, occlusion, or dissection.
OTHER:
The visualized portion of the lungs are clear. There is an 8 mm hypodense
left lobe thyroid nodule. There is no lymphadenopathy by CT size criteria.
There is mild multilevel cervical spondylosis.
IMPRESSION:
1. No acute intracranial abnormality.
2. Patent intracranial arterial vasculature without significant stenosis,
occlusion, or aneurysm.
3. 75% left and 10% right internal carotid artery stenosis by NASCET criteria.
4. Minimal nonocclusive narrowing of left vertebral artery origin. Otherwise
patent cervical arterial vasculature without additional areas of significant
stenosis, occlusion, or evidence of dissection.
5. Severe paranasal sinus disease, as described, with areas of aerosolized
fluid suggestive of active inflammation.
6. Periapical lucency surrounding what appears to be a residual fragment of
the left maxillary lateral incisor, compatible with periodontal disease.
Formal dental evaluation is advised.
7. 8 mm hypodense left thyroid lobe nodule. The ___ College of Radiology
guidelines suggest that in the absence of risk factors for thyroid cancer, no
further evaluation is recommended.
RECOMMENDATION(S):
1. Periapical lucency surrounding what appears to be a residual fragment of
the left maxillary lateral incisor, compatible with periodontal disease.
Formal dental evaluation is advised.
2. Thyroid nodule. No follow up recommended.
Absent suspicious imaging features, unless there is additional clinical
concern, ___ College of Radiology guidelines do not recommend further
evaluation for incidental thyroid nodules less than 1.0 cm in patients under
age ___ or less than 1.5 cm in patients age ___ or ___.
Suspicious findings include: Abnormal lymph nodes (those displaying
enlargement, calcification, cystic components and/or increased enhancement) or
invasion of local tissues by the thyroid nodule.
___, et al, "Managing Incidental Thyroid Nodules Detected on Imaging: White
Paper of the ACR Incidental Findings Committee". J ___ ___
12:143-150.
Radiology Report
EXAMINATION: MR HEAD W/O CONTRAST T___ MR HEAD
INDICATION: ___ male with left-sided weakness. Evaluate for infarct.
TECHNIQUE: Sagittal T1 weighted imaging was performed. Axial imaging was
performed with gradient echo, FLAIR, diffusion, and T2 technique were then
obtained.
COMPARISON ___, outside hospital noncontrast head CT.
___, contrast head MRI and MRA.
___, contrast head and neck CTA.
FINDINGS:
Study is mildly degraded by motion. There is no evidence of hemorrhage,
edema, masses, mass effect, midline shift or infarction. The ventricles and
sulci are normal in caliber and configuration for age. Areas of scattered
periventricular, subcortical and deep white matter T2/FLAIR hyperintensities
are in a configuration most suggestive of chronic small vessel ischemic
disease. There is no abnormal focus of slowed diffusion. The principal
intracranial vascular flow voids are preserved.
There is mild polypoid mucosal wall thickening in the bilateral maxillary and
left sphenoid sinuses. There is aerosolized fluid in the right maxillary
sinus. There is near complete opacification of the right sphenoid sinus and
near complete opacification of the bilateral ethmoid air cells. There is mild
moderate mucosal wall thickening of the bilateral frontal sinuses. There are
changes from bilateral lens replacement surgery. The orbits otherwise grossly
unremarkable. There is no abnormal fluid signal in the mastoid air cells.
IMPRESSION:
1. Study is mildly degraded by motion.
2. No acute intracranial abnormality including hemorrhage or infarct.
3. Extensive paranasal sinus disease concerning for acute sinusitis, as
described.
Gender: M
Race: OTHER
Arrive by AMBULANCE
Chief complaint: Dizziness, Headache, L Weakness
Diagnosed with Cerebral infarction, unspecified
temperature: 96.9
heartrate: 64.0
resprate: 16.0
o2sat: 98.0
sbp: 143.0
dbp: 74.0
level of pain: 4
level of acuity: 2.0 | Pt was admitted to ___ due to LUE and face weakness concerning
for stroke. While on Stroke service, he was monitored on
telemetry and underwent imaging workup with CT and MRI. CTA
showed L ICA stenosis~70% although appears unrelated to pt's
symptoms. MRI performed showed no acute infarct. While admitted,
pt's home Aspirin was continued. Due to ICA stenosis and LDL, pt
was transitioned from home Pravastatin to Rosuvastatin. Due to
appearing clnically stable with no need for further
rehabilitation, patient was discharged home with appropriate
follow up. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Zantac / Amoxicillin / Lamisil / Penicillins / Levaquin
Attending: ___.
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
___ s/p Sapian ___ilateral femoral groin access
History of Present Illness:
___ with a history of cad s/p RCA stent (98/99) and LAD
(___), PAF on coumadin, diabetes, s/p AVJ ablation and
___ PPM (gen changed ___, chronic systolic heart failure
(25%) and severe aortic stenosis who initially presented with
SOB.
Patient was transferred from ___ for work-up of aortic
valve replacement. He was recently admitted here from ___ -
___ for a very similar presentation. He was diuresed in the
hospital and felt to not require diuretics upon discharge. Since
then, he has had gradually progressive SOB that became
significantly worse in the past 3 days. The SOB is worse with
exertion, and not pleuritic in nature. He has also noted a
weight gain of ___ over the past 4 days. He feels like it has
been harder to button his pants.
The patient underwent TAVR on ___ with successful
implantation of ___ 3 with no complications.
On arrival to the CCU, patient is alert and oriented and has no
complaints. Vitals are: T 96.2, HR 65 in AF V-Paced, BP 156/50,
RR 15, 100% RA.
Past Medical History:
-Coronary artery disease : s/p RCA stents 98, 99. s/p PCI to LAD
in ___
-Paroxysmal atrial fibrillation s/p AV ablation and pacemaker
-Hypertension
-Hyperlipidemia
-Diabetes type II
-Melanoma
-Meningitis (residual numbness tingling is baseline)
-s/p tracheostomy
-Hearing loss
-Esophageal stricture with dilatation
-GERD
Social History:
___
Family History:
Non-contributory
Physical Exam:
ADMISSION PHYSICAL EXAM
=============================
VS:
GENERAL: Well developed, well nourished in NAD. Oriented x3.
Nasal cannula in place.
HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI.
Conjunctiva were pink. No pallor or cyanosis of the oral mucosa.
No xanthelasma.
NECK: Supple. LVEDP 35 in cath lab.
CARDIAC: Regular rate and rhythm. Normal S1, S2. No murmurs,
rubs, or gallops.
LUNGS: No chest wall deformities or tenderness. Respiration is
unlabored with no accessory muscle use. No crackles, wheezes or
rhonchi.
ABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No
splenomegaly.
EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or
peripheral edema.
SKIN: No significant skin lesions or rashes.
PULSES: Distal pulses palpable and symmetric.
ON Discharge ___:
VS: T 98.9 HR 67 RR 18 BP 153/54 98% RA
tele ___ vpaced
General: A&O x 3 NAD
HEENT: supple, non-distended JVP
CV: RRR normal S1, S2 II/VI murmur best heart RUSB
LUNGS: CTAB, decreased air exchange bases
ABDOMEN: soft, NT, +BS
Extremities: warm and dry, B groin sites d/I (left with
staining), mild ecchymosis noted R>L, resolving hematoma on the
right, without bleed or bruit bilaterally, +1DP no edema
Skin:warm and dry
The patient was seen by Dr. ___ and was deemed
appropriate for discharge at 14:29 ___ ___.
Pertinent Results:
ADMISSION LABS:
___ 08:15AM BLOOD WBC-8.8 RBC-3.28* Hgb-10.9* Hct-32.2*
MCV-98 MCH-33.2* MCHC-33.9 RDW-13.8 RDWSD-49.6* Plt ___
___ 08:15AM BLOOD ___ PTT-47.6* ___
___ 08:15AM BLOOD Glucose-118* UreaN-40* Creat-1.5* Na-141
K-4.3 Cl-107 HCO3-21* AnGap-17
___ 08:06PM BLOOD ALT-31 AST-27 CK(CPK)-51 AlkPhos-63
TotBili-0.9
___ 08:15AM BLOOD proBNP-8597*
___ 08:15AM BLOOD cTropnT-0.03*
___ 08:06PM BLOOD Albumin-4.0 Calcium-9.2 Phos-4.1 Mg-1.9
___ 08:06PM BLOOD TSH-0.25*
___ 06:57AM BLOOD WBC-8.7 RBC-3.54* Hgb-11.4* Hct-34.3*
MCV-97 MCH-32.2* MCHC-33.2 RDW-14.0 RDWSD-48.9* Plt ___
___ 06:28AM BLOOD WBC-8.3 RBC-3.37* Hgb-10.6* Hct-32.3*
MCV-96 MCH-31.5 MCHC-32.8 RDW-13.9 RDWSD-48.0* Plt ___
___ 06:25AM BLOOD WBC-7.4 RBC-3.19* Hgb-10.2* Hct-31.2*
MCV-98 MCH-32.0 MCHC-32.7 RDW-13.7 RDWSD-48.8* Plt ___
___ 04:36AM BLOOD WBC-6.8 RBC-3.18* Hgb-10.3* Hct-30.4*
MCV-96 MCH-32.4* MCHC-33.9 RDW-13.8 RDWSD-48.7* Plt ___
___ 06:10AM BLOOD WBC-7.6 RBC-3.02* Hgb-9.7* Hct-29.6*
MCV-98 MCH-32.1* MCHC-32.8 RDW-13.8 RDWSD-48.9* Plt ___
___ 06:10AM BLOOD Plt ___
___ 06:10AM BLOOD ___
___ 04:36AM BLOOD ___
___ 03:45PM BLOOD ___ PTT-32.0 ___
___ 06:25AM BLOOD ___ PTT-33.9 ___
___ 06:28AM BLOOD ___ PTT-39.2* ___
___ 06:10AM BLOOD Glucose-162* UreaN-32* Creat-1.4* Na-141
K-4.2 Cl-105 HCO3-22 AnGap-18
___ 04:36AM BLOOD Glucose-148* UreaN-28* Creat-1.4* Na-142
K-3.3 Cl-104 HCO3-26 AnGap-15
___ 03:45PM BLOOD Glucose-179* UreaN-32* Creat-1.3* Na-140
K-4.0 Cl-106 HCO3-24 AnGap-14
___ 06:25AM BLOOD Glucose-157* UreaN-38* Creat-1.5* Na-143
K-4.4 Cl-106 HCO3-28 AnGap-13
___ 06:28AM BLOOD Glucose-168* UreaN-36* Creat-1.4* Na-142
K-4.3 Cl-106 HCO3-24 AnGap-16
___ 03:05PM BLOOD Glucose-193* UreaN-41* Creat-1.6* Na-142
K-4.3 Cl-106 HCO3-24 AnGap-16
___ 06:57AM BLOOD Glucose-156* UreaN-34* Creat-1.5* Na-142
K-4.4 Cl-104 HCO3-24 AnGap-18
___ 12:04AM BLOOD Glucose-157* UreaN-38* Creat-1.6* Na-142
K-3.5 Cl-106 HCO3-22 AnGap-18
___ 06:28AM BLOOD CK-MB-3 cTropnT-<0.01
___ 06:57AM BLOOD CK-MB-3 cTropnT-0.02*
___ 04:36AM BLOOD Calcium-8.6 Phos-4.1 Mg-1.6
___ 03:45PM BLOOD Calcium-8.7 Phos-3.9 Mg-1.7
___ 06:25AM BLOOD Calcium-8.9 Phos-3.7 Mg-1.8
___ 03:05PM BLOOD Calcium-9.1 Phos-4.3 Mg-2.1
URINE:
___ 09:31PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-SM
___ 9:31 pm URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___:
KLEBSIELLA PNEUMONIAE. 10,000-100,000 ORGANISMS/ML..
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 64 I
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
STUDIES:
___ Successful implantation of TAVR. Final report not
available at time of discharge summary.
___ ULTRASOUND RIGHT FEMORAL ARTERY
No evidence of pseudoaneurysm or hematoma.
PORTABLE TTE ECHO ___:
The left atrium is mildly dilated. The right atrium is
moderately dilated. Left ventricular wall thicknesses and cavity
size are normal. Overall left ventricular systolic function is
moderately depressed (LVEF= 35 %). Global hypokinesis is seen
with relative sparing of the basal segments. Right ventricular
chamber size is normal with borderline normal free wall
function. A ___ 3 aortic valve bioprosthesis is present. The
transaortic gradient is normal for this prosthesis. A
paravalvular jet of trace aortic regurgitation is seen. The
aortic valve VTI = 31.9 cm. Trace aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. Moderate (2+)
mitral regurgitation is seen. Moderate to severe [3+] tricuspid
regurgitation is seen. [Due to acoustic shadowing, the severity
of tricuspid regurgitation may be significantly UNDERestimated.]
There is no pericardial effusion.
IMPRESSION: Normally functioning ___ 3 aortic valve with a
trace paravalvular leak. Moderately depressed left ventricular
systolic function. Mild mitral regurgitation. Moderate to severe
tricuspid regurgitation.
Compared with the prior study (images reviewed) of ___,
there has been interval placement of ___ 3 aortic valve.
Severe aortic stenosis is no longer appreciated. The global left
ventricular systolic function appears slightly more vigorous.
The severity of tricuspid regurgitation may have increased (was
not well assessed in the apical view on the prior study).
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin EC 81 mg PO DAILY
2. Clopidogrel 75 mg PO DAILY
3. Lisinopril 2.5 mg PO QHS
4. MetFORMIN (Glucophage) 1000 mg PO BID
5. Pantoprazole 40 mg PO Q24H
6. Warfarin 6 mg PO 2X/WEEK (___)
7. Warfarin 5 mg PO 5X/WEEK (___)
8. Januvia (sitaGLIPtin) 100 mg oral DAILY
9. GuaiFENesin ___ mL PO Q6H:PRN cough
10. GuaiFENesin ER 1200 mg PO Q12H
11. Amiodarone 400 mg PO DAILY
12. Atorvastatin 40 mg PO QPM
13. Carvedilol 6.25 mg PO BID
Discharge Medications:
1. Amiodarone 400 mg PO DAILY
2. Aspirin EC 81 mg PO DAILY
3. Atorvastatin 40 mg PO QPM
4. Carvedilol 6.25 mg PO BID
5. Lisinopril 2.5 mg PO QHS
6. Pantoprazole 40 mg PO Q24H
7. Warfarin 6 mg PO 2X/WEEK (___)
8. Warfarin 5 mg PO 5X/WEEK (___)
9. GuaiFENesin ___ mL PO Q6H:PRN cough
10. GuaiFENesin ER 1200 mg PO Q12H
11. Januvia (sitaGLIPtin) 100 mg oral DAILY
12. MetFORMIN (Glucophage) 1000 mg PO BID
13. Sulfameth/Trimethoprim DS 1 TAB PO BID
x 5 days; check your BUN/Creatinine in 3 days
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
acute on chronic systolic heart failure
s/p TAVR for aortic stenosis
Discharge Condition:
___ year old male transferred from ___ with history of
CAD s/p stent ___, PAF on Coumadin, diabetes, s/p AVJ
ablation and pacemaker, and chronic systolic heart failure with
worsening aortic stenosis for TAVR evaluation; underwent ___
3 TAVR procedure ___ found to have urinary tract infection
so started on Bactrim DS; echo ___ showed no significant AI;
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Plan:
# Severe aortic stenosis: s/p successful implantation ___
3 valve.
- activity and groin care reviewed
- f/u with Dr. ___ with outpatient echo
# Acute on chronic systolic heart failure with reduced EF: LVEF
of 25% as of ___, post TAVR echo EF 35%
- daily weights
- Continue home Aspirin EC 81 mg PO DAILY, Lisinopril 2.5 mg PO
QHS, Carvedilol 6.25 mg PO BID
# NSTEMI, Type II: Demand ischemia in the setting of acute on
chronic heart failure. Trops peaked at 0.03 on ___.
# CAD s/p DES to LAD ___:
- continue Aspirin EC 81 mg PO DAILY, Atorvastatin 40 mg PO
QPM, Carvedilol 6.25 mg PO BID.
- Will D/C Plavix now that therapeutic on coumadin (pt already
had >6 months of DAPT) per Dr. ___
# Paroxysmal afib s/p ablation:
- Coumadin at usual dosing for goal INR 2.0- 3.0
- continue Carvedilol 6.25 mg PO BID, Amiodarone 400 mg PO
DAILY
- recheck INR in ___ days as outpatient -- Management per ___
___ clinic
#Hypertension:
- Continuing home Lisinopril 2.5 mg PO QHS, Carvedilol 6.25 mg
PO
#Hyperlipidemia:
- continue home atorvastatin 40mg daily
#Diabetes type II: on Januvia and metformin at home.
- HISS
- resume Januvia and metformin ___
#GERD: on pantoprazole 40mg daily
- continue home pantoprazole 40mg daily
#UTI -- asymptomatic
- Keflex x 7 days
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with severe AS s/p TAVR // post-op CXR s/p TAVR
TECHNIQUE: Single frontal view of the chest
COMPARISON: ___.
IMPRESSION:
Moderate to severe cardiomegaly is stable. Aortic stent is in place. Pacer
leads are in standard position. There is mild vascular congestion. Bibasilar
atelectasis larger on the left side have improved. There is no pneumothorax
or pleural effusion
Radiology Report
EXAMINATION: NON-INVASIVE PERIPHERAL ARTERIAL STUDY
INDICATION: ___ year old man AFib on Coumadin, s/p TAVR, evaluate for
pseudoaneurysm R groin
TECHNIQUE: Grayscale, color Doppler, and spectral Doppler images of the right
lower extremity were performed.
COMPARISON: None.
FINDINGS:
Targeted imaging in the area of clinical concern reveals normal arterial and
venous waveforms within the common femoral artery and common femoral vein,
respectively. There is no evidence of pseudoaneurysm or hematoma.
IMPRESSION:
No evidence of pseudoaneurysm or hematoma.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Dyspnea, Transfer
Diagnosed with Nonrheumatic aortic (valve) stenosis
temperature: 98.2
heartrate: 89.0
resprate: 20.0
o2sat: 98.0
sbp: 152.0
dbp: 55.0
level of pain: 0
level of acuity: 2.0 | ___ with a history of CAD, PAF s/p AVJ ablation, DM, HFrEF (EF
25%), and severe aortic stenosis, admitted for TAVR.
# Severe aortic stenosis: Patient underwent successful
implantation ___ 3 AVR on ___. He was admitted to CCU
for close post-procedure monitoring. Because of concern for
right groin swelling he had ultrasound of this site which was
normal. He was transferred to floor. He ambulated with ___ and
was deemed appropriate for discharge to home with continued
physical therapy.
# Acute on chronic systolic heart failure: LVEF of 25% as of
___, admitted with evidence of volume overload. LHC during
TAVR with LVEDP 36. He was continued on his home medications and
diuresed as needed with IV Lasix. He was discharged to home on a
low dose diuretic (resumed chronic 20 mg Daily Lasix with hold
parameters - escripted to his pharmacy)
# CAD s/p DES to LAD ___: Patient had CP with exertion on
admission with troponin peak to 0.03. ECG was unchanged. He was
continued on home regimen of ASA, Plavix, atorvastatin,
carvedilol, lisinopril. Once therapeutic on warfarin post-TAVR
his Plavix was discontinued since he had completed 6 months of
therapy per Dr. ___.
# Paroxysmal atrial fibrillation: Warfarin was held for his TAVR
and restarted post-procedure. Once therapeutic his Plavix was
discontinued (see above).
# UTI - his urine showed Klebsiella Pneumoniae although he
remained asymptomatic and afebrile with no leukocytosis. He was
discharged on 5 days of Bactrim DS given he is currently on
Amiodarone and oral Ciprofloxacin was not an option due to its
interaction and possible prolongation of the QT interval. Given
his creatinine is currently 1.4, he should have his
BUN/Creatinine checked in three days when his INR is next
checked at ___. Results should be sent to his PCP.
We recommend a repeat UA and culture when he follows up with his
PCP to ensure his UTI was appropriately treated.
CHRONIC ISSUES
#Diabetes type II: on Januvia and metformin at home. Sliding
scale insulin in house.
#GERD: Continued home pantoprazole 40mg daily.
# CODE: Full
# CONTACT/HCP: ___ (wife): ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Lantus / Prochlorperazine
Attending: ___
Chief Complaint:
Acute Renal Failure
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ male with history of HCV cirrhosis s/p liver
transplant c/b by graft cirrhosis due to HCV recrudescence
presented to the ED from his PCP's office due to elevated
creatinine to 3.4 (baseline creatinine is 1.9) noted on
scheduled labs on ___.
Mr. ___ was recently hospitalized ___ with acute renal
failure in the setting of NSAID (Ibuprofen) overuse to treat
pain from Herpes Zoster s/p valcyclovir. Patient was discharged
home on ___ with a serum creatinine of 2.8. He was scheduled
for a post-discharge follow-up appointment and lab check with
his PCP ___ ___, at which time his creatinine was noted to be
elevated to 3.4. At this point he was sent to the ___ ED.
Patient states that since his discharge he has been increasingly
bothered by back pain from his zoster infection. This pain is
right-sided, lower back and dull. It is worse with movement and
does not radiate. He has taken no medication for it since his
last admission--namely, he has avoided ibuprofen and Tylenol.
In the time since discharge, he endorses urinary frequency.
He denies fevers, chills, abdominal pain, dysuria, urinary
hesitancy, and lower extremity edema worse than baseline.
Incidentally, Mr. ___ notes that he vomited once on ___
___, just after eating breakfast. The vomitus was nonbloody,
nonbilious, no coffee ground emesis. He felt back to his
baseline immediately afterward and has had no nausea or vomiting
since.
In addition, Mr. ___ describes a syncopal episode during
which he lost consciousness for a few seconds while driving on
___. He states that he felt flushed and faint and then his
vision went black. He was able to move his foot to the break and
stop. He quickly regained full consciousness and felt back at
his baseline. Had full memory of the event, denied loss of bowel
or bladder function. He reports that he has had a few
near-syncopal episodes recently when going from sitting to
standing; he attributes this to his blood pressure.
Past Medical History:
- HCV cirrhosis (genotype 1a) s/p OLT ___ years prior complicated
by graft cirrhosis, now cured s/p Harvoni
-> EGD ___ w/o varices
-> no hx of Hepatic encephalopathy
-> no ascites
-> RUQ US ___: no masses
-> Immunosuppression: On tacrolimus monotherapy
- DLBCL s/p 6 cycles of CHOP, most recent PET without disease
- Chronic Kidney Disease: Seen by Dr. ___. Baseline
Cr=1.5-1.8 before recent admission, last discharge Cr=2.8
- Hypertension
- DM2: A1c 10.6% ___ Admission ___ for hyperglycemia
- Peripheral neuropathy on gabapentin
- Chronic headaches thought ___ immunosuppression medications
- Anemia: normal colonoscopy ___. EGD ___ without varices,
gastric/duodenal ulcers.
- Thrombocytopenia
Social History:
___
Family History:
Mother - died ___ heart failure.
Father - died ___ prostate cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
Vital Signs: T 97.9 HR 71 BP 182/94 RR 24 O2 100% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred.
DISCHARGE PHYSICAL EXAM
=======================
Vital Signs: 97.9 PO 146 / 81 76 18 97 RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops. Port in place on right side of chest with no erythema.
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding. Surgical scars--midline
and transverse. Mesh in right side of abdomen.
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis.
Trace edema.
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, normal gait
Pertinent Results:
ADMISSION LABS
==============
___ 10:00PM BLOOD WBC-4.0 RBC-3.18* Hgb-9.9* Hct-29.5*
MCV-93 MCH-31.1 MCHC-33.6 RDW-15.9* RDWSD-52.7* Plt Ct-83*
___ 10:00PM BLOOD Neuts-47.7 ___ Monos-10.6 Eos-4.8
Baso-0.8 Im ___ AbsNeut-1.90 AbsLymp-1.42 AbsMono-0.42
AbsEos-0.19 AbsBaso-0.03
___ 10:00PM BLOOD Plt Ct-83*
___ 10:00PM BLOOD Glucose-138* UreaN-44* Creat-2.9* Na-139
K-3.9 Cl-109* HCO3-20* AnGap-14
___ 10:00PM BLOOD Calcium-8.5 Phos-3.4 Mg-1.4*
IMAGING
=======
Renal Ultrasound ___
IMPRESSION:
Bilateral increased renal cortical echogenicity suggestive of
medical renal disease. No hydronephrosis or obstructive cause
___ identified.
DISCHARGE LABS
==============
___ 05:08AM BLOOD WBC-3.5* RBC-3.23* Hgb-10.1* Hct-29.7*
MCV-92 MCH-31.3 MCHC-34.0 RDW-15.6* RDWSD-50.9* Plt Ct-97*
___ 05:08AM BLOOD Plt Ct-97*
___ 05:08AM BLOOD Glucose-90 UreaN-40* Creat-2.4* Na-140
K-3.8 Cl-108 HCO3-22 AnGap-14
___ 05:08AM BLOOD ALT-25 AST-20 LD(LDH)-181 AlkPhos-82
TotBili-0.3
___ 05:08AM BLOOD Calcium-8.5 Phos-3.4 Mg-2.0
___ 05:03AM BLOOD calTIBC-181* ___ Ferritn-129
TRF-139*
___ 09:00AM BLOOD tacroFK-3.1*
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Diltiazem Extended-Release 240 mg PO DAILY
2. Ferrous Sulfate 325 mg PO DAILY
3. Gabapentin 200 mg PO BID
4. OLANZapine 5 mg PO QHS
5. Omeprazole 20 mg PO DAILY
6. PARoxetine 40 mg PO DAILY
7. Tacrolimus 1 mg PO Q12H
8. Thiamine 100 mg PO DAILY
9. HydrALAZINE 50 mg PO TID
10. Levemir (insulin detemir) 80 units subcutaneous BREAKFAST
11. Levemir (insulin detemir) 80 units subcutaneous QHS
Discharge Medications:
1. Lidocaine 5% Patch 1 PTCH TD QAM
RX *lidocaine 5 % Please place 1 patch in the affected area once
a day Disp #*30 Patch Refills:*0
2. Diltiazem Extended-Release 240 mg PO DAILY
3. Ferrous Sulfate 325 mg PO DAILY
4. Gabapentin 200 mg PO BID
5. HydrALAZINE 50 mg PO TID
6. Levemir (insulin detemir) 80 units SUBCUTANEOUS QHS
7. Levemir (insulin detemir) 80 units SUBCUTANEOUS BREAKFAST
8. OLANZapine 5 mg PO QHS
9. Omeprazole 20 mg PO DAILY
10. PARoxetine 40 mg PO DAILY
11. Tacrolimus 1 mg PO Q12H
12. Thiamine 100 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
1. Acute Kidney Injury
2. HCV Cirrhosis s/p transplant
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: RENAL U.S.
INDICATION: ___ year old man with ___ on CKD, cirrhosis s/p liver transplant
// Please eval for hydronephrosis, obstructive causes ___
TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were
obtained.
COMPARISON: Abdominal ultrasound ___ abdominal ultrasound ___
FINDINGS:
The right kidney is poorly visualized and measures 11.4 cm. The left kidney
measures 12.2 cm. There is no hydronephrosis, stones, or masses bilaterally.
Re-identification of a right interpolar cyst measuring 1.24 x 0.96 x 0.98 cm.
Increased cortical echogenicity seen bilaterally suggestive of medical renal
disease.
The bladder is moderately well distended and normal in appearance.
IMPRESSION:
Bilateral increased renal cortical echogenicity suggestive of medical renal
disease. No hydronephrosis or obstructive cause ___ identified.
Gender: M
Race: BLACK/CAPE VERDEAN
Arrive by WALK IN
Chief complaint: Abnormal labs, Back pain
Diagnosed with Acute kidney failure, unspecified
temperature: 97.6
heartrate: 76.0
resprate: 18.0
o2sat: 98.0
sbp: 126.0
dbp: 71.0
level of pain: 6
level of acuity: 2.0 | ___ M with a h/o HCV cirrhosis s/p OLT ___ c/b graft
cirrhosis, B-Cell Lymphoma in remission, DM, recent
hospitalization for ___ on CKD, and recent VZV s/p valcyclovir
with concern for ___. Patient admitted with outpatient labs
indicating an ___, which showed some improvement from prior
hospitalization. Patient was given IVF for pre-renal etiology,
and labs trended. Furthermore, patient had a pre-syncopal
episode, was continued on telemetry without any alarms for > 24
hours, and negative orthostatic vitals. Patient was able to
ambulate with nursing without any significant issues, and was
started on lidocaine to help with pain symptoms in an attempt to
avoid any NSAIDs that could worsen kidney injury. Patient's
tacrolimus levels were then drawn, and monitored without any
dosage changes.
# Normocytic Anemia: Incidentally found to have decreased Hgb=10
compared to baseline of ___. No recent history of bleeding.
Denies melena, hematochezia, hematemesis. Last workup for
varices EGD in ___ with no varices or UGIB.
Discharge H/H in AM is ~10. Hemolysis labs and ferritin wnl.
TIBC is low which may be more consistent with hepatic disease.
Consider repeat EGD and colonoscopy with outpatient prep.
# ___ on CKD: Discharge Cr is 2.4. Per report, Mr. ___
serum Cr up to 3.4 at ___'s office on ___ however, at ___ ED
Cr down to 2.9, comparable to last discharge creatinine. Denies
recent exposure to ibuprofen or nephrotoxic meds. Could be
pre-renal as patient has poor po intake and complains of
lightheadedness.
# Syncope/Presyncope: Episode of syncope/pre-syncope while
driving concerning for vasovagal vs. cardiogenic syncope. On an
intense BP regimen with history congruent with orthostatic
hypotension; however orthostatic vitals negative. Seizure very
unlikely given history but notes that this will occur at random
times. Could be hypoglycemic.
# Back pain: Most likely secondary to shingles, given timing and
character of pain. However, given alterations in kidney function
and ___ be renal in origin. Likewise, may represent
worsening lumbago of MSK origin. Worked up at last admission and
unrevealing; apparently resolved prior to last discharge. He was
given lidocaine patch and oxycodone with significant relief.
Home gabapentin
- APAP 500 mg Q8H
- Oxycodone 10mg PRN for breakthrough overnight
- Restart home gabapentin. Will think about increasing
gabapentin if not controlled or starting a TCA.
# HCV cirrhosis: s/p OLT ___, and recurrent HCV in graft cured
with Harvoni. On tacrolimus 1mg BID after recent decrease from
1.5 mg BID due to high trough levels. On last discharge
tacrolimus level was 7.9.
- Continue tacro at 1mg BID
- Daily Tacro levels
================ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Ultram / Methadone / Avelox / Cymbalta
Attending: ___.
Chief Complaint:
Fever, Cough x 3d
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with PMH myasthenia ___, afib w ICD, CAD s/p MI, CHF, ITP
s/p splenectomy p/w fever recorded at rehab. Patient was
admitted s/p fall from ___. For the past 3 days has
experienced fever up to ___, as well as chills and night
sweats. The patient has noticed increasing urinary retention sx
of dribbling and hesitancy for the past few days. He denies
current dysuria, hematuria, or suprapubic pressure. He says his
urine intermittently is dark or foul smelling.
Continues to have persistent left sided chest wall and flank
pain that is unchanged since his fall. He has had cough
productive of brown sputum for ___ weeks. He has had throat pain
related to his sputum. He has been experiencing R sided chest
pressure associated with eating, non-exertional. He has been
having SOB intermittently for ___ weeks.
No headache, dyspnea, nausea, vomiting, dysuria, diarrhea.
In the ED, initial vitals 97.9 63 100/55 19 99%. He was given
Dilaudid, CTX, and azithromycin.
ROS: positive per HPI (see above). denies constipation,
diarrhea, vomiting, blood per rectum.
Past Medical History:
1. Myasthenia ___ - last admission ___
2. Atrial Fibrillation s/p AICD, PPM
3. Coronary Artery Disease s/p MI ___, CABG x4 in ___, CHF
4. Obstructive Sleep Apnea
5. ITP s/p splenectomy
6. CHF with EF 40% by TTE ___
7. Hypertension
8. Hypercholesterolemia
9. Depression
10. Lupus anticoagulant c/b PE and DVT on AC
11. 5 back surgeries per patient
12. hernia repair ___. left THR ___. multiple level degenerative changes Lumbar and cervical
spine
15. complete heart block s/p pacemaker insertion
16. reports crush injury to the right leg about ___ years ago,
with subsequent right foot drop. uses a cane ever since then.
17. Uvulopalatopharyngoplasty in the 1980s for OSA.
18. Pulmonary nodules ___hest)
Social History:
___
Family History:
father - ___ in his ___, leukemia
brother - ___ in his ___
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS - 98.2 99/62 66 16 98% 2L
GENERAL - Obese, in pain but improved
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no JVD, no carotid bruits, no LAD
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2, distant heart
sounds
ABDOMEN - NABS, soft/ND, mildly tender to palpation on RUQ and
LUQ, no masses or HSM, no rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (DPs)
SKIN - no rashes or lesions
DISCHARGE PHYSICAL EXAM:
VS- 98.7 110-114/57-65 59-69 16 97%RA
HEENT- MMM, no oral erythema, unable to assess JVD, no LAD
Pulm- Crackles at bases b/l improve with subsequent breaths, no
wheezes
CV- Distant, S1S2 RRR no m/g/c/r
Abd- Soft, nt/nd, no organomegaly, BS+
Ext- No c/c/e
Pertinent Results:
ADMISSION LABS:
___ 01:20PM BLOOD WBC-13.2* RBC-4.27* Hgb-12.9* Hct-40.3
MCV-95 MCH-30.3 MCHC-32.1 RDW-15.7* Plt ___
___ 01:20PM BLOOD Neuts-88.3* Lymphs-5.0* Monos-5.7 Eos-0.9
Baso-0.2
___ 01:20PM BLOOD ___ PTT-39.5* ___
___ 01:20PM BLOOD Glucose-101* UreaN-14 Creat-0.8 Na-139
K-4.4 Cl-102 HCO3-30 AnGap-11
___ 01:20PM BLOOD CK(CPK)-33*
___ 01:20PM BLOOD CK-MB-2 cTropnT-<0.01
___ 11:04PM BLOOD CK-MB-2 cTropnT-<0.01
___ 11:04PM BLOOD CK(CPK)-31*
___ 05:50AM BLOOD Calcium-9.0 Phos-3.0 Mg-1.7
___ 01:40PM BLOOD Lactate-1.3
___ 11:46PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-4* pH-5.5 Leuks-NEG
___ 11:46PM URINE RBC-2 WBC-4 Bacteri-FEW Yeast-NONE Epi-0
DISCHARGE LABS:
___ 01:54PM BLOOD WBC-6.0 RBC-4.15* Hgb-12.2* Hct-38.7*
MCV-93 MCH-29.5 MCHC-31.6 RDW-15.5 Plt ___
___ 01:54PM BLOOD Glucose-102* UreaN-19 Creat-0.9 Na-134
K-4.0 Cl-99 HCO3-31 AnGap-8
___ 01:54PM BLOOD Calcium-9.1 Phos-1.8* Mg-1.8
IMAGING:
CXR
1. Blunting of posterior costophrenic angle on the lateral view
may be
technical, although trace pleural effusions may be present.
2. Persistent cardiomegaly. Possible minimal pulmonary
vascular congestion.
Barium Swallow
Normal esophagram with no evidence of stricture or narrowing.
EKG x3: No ST/T Changes, stable
MICROBIOLOGY:
Blood Cx x2 Negative
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. Aspirin EC 325 mg ___ DAILY
2. Dabigatran Etexilate 150 mg ___ BID
3. Diazepam 10 mg ___ Q8H:PRN insomnia
4. Lisinopril 10 mg ___ DAILY
5. Docusate Sodium 100 mg ___ BID:PRN constipation
6. Metoprolol Succinate XL 100 mg ___ DAILY
7. MetronidAZOLE Topical 1 % Gel 1 Appl TP DAILY:PRN rash
8. Mycophenolate Mofetil 1500 mg ___ BID
9. Pantoprazole 40 mg ___ Q24H
10. PredniSONE 15 mg ___ DAILY
11. Rosuvastatin Calcium 20 mg ___ DAILY
12. Sertraline 200 mg ___ DAILY
13. HYDROmorphone (Dilaudid) ___ mg ___ Q3H:PRN pain
please give 2 mg first, reassess 1 hr later, can give second
dose if alert and still in pain. hold for sedation
14. azelastine *NF* 137 mcg NU BID prn post nasal drip
15. Diphenoxylate-Atropine 1 TAB ___ Q6H:PRN diarrhea
16. Ferrous Sulfate 325 mg ___ BID
17. Furosemide 40 mg ___ DAILY
18. modafinil *NF* 200 mg Oral daily
19. Polyethylene Glycol 17 g ___ DAILY:PRN constipation
Discharge Medications:
1. Aspirin EC 325 mg ___ DAILY
2. Dabigatran Etexilate 150 mg ___ BID
3. Diazepam 10 mg ___ Q8H:PRN insomnia
4. Docusate Sodium 100 mg ___ BID:PRN constipation
5. Ferrous Sulfate 325 mg ___ BID
6. Furosemide 40 mg ___ DAILY
7. Lisinopril 10 mg ___ DAILY
8. Metoprolol Succinate XL 100 mg ___ DAILY
9. MetronidAZOLE Topical 1 % Gel 1 Appl TP DAILY:PRN rash
10. Mycophenolate Mofetil 1500 mg ___ BID
11. Pantoprazole 40 mg ___ Q24H
12. Polyethylene Glycol 17 g ___ DAILY:PRN constipation
13. PredniSONE 15 mg ___ DAILY
14. Rosuvastatin Calcium 20 mg ___ DAILY
15. Sertraline 200 mg ___ DAILY
16. azelastine *NF* 137 mcg NU BID prn post nasal drip
17. Diphenoxylate-Atropine 1 TAB ___ Q6H:PRN diarrhea
18. modafinil *NF* 200 mg Oral daily
19. HYDROmorphone (Dilaudid) ___ mg ___ Q6H:PRN pain
take 2mg first, if alert after 30min, take 2mg again
RX *hydromorphone 2 mg ___ tablet(s) by mouth every 6 hours Disp
#*60 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
Primary: Bronchitis, Dysphagia
Secondary: Myasthenia ___, CAD, CHF, HTN, Atrial
Fibrillation, OSA, Spinal Stenosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAM: Chest frontal and lateral views.
CLINICAL INFORMATION: ___ male with history of status post chest
trauma, fever.
___.
FINDINGS: Frontal and lateral views of the chest were obtained. The patient
is status post median sternotomy. A dual-lead left-sided pacemaker is seen
with leads in the expected positions of the right atrium and right ventricle.
The posterior costophrenic angles are not well seen on the lateral view which
may be technical, although trace pleural effusions may be present. No focal
consolidation or pneumothorax is seen. The cardiomediastinal silhouette is
stable, with persistent cardiomegaly. There is possible minimal pulmonary
vascular congestion.
IMPRESSION:
1. Blunting of posterior costophrenic angle on the lateral view may be
technical, although trace pleural effusions may be present.
2. Persistent cardiomegaly. Possible minimal pulmonary vascular congestion.
Radiology Report
HISTORY: ___ man with worsening dysphagia over the past few weeks,
evaluate for obstruction/dysmotility.
COMPARISON: None available.
ESOPHAGRAM: Barium passes freely through the esophagus to the stomach with
normal primary peristaltic contractions. The caliber and contour of the
esophagus is normal with no evidence of focal narrowing or stricture. No
hiatal hernia. A 13-mm barium tablet was given which was momentarily held up
at the level of the GE junction.
IMPRESSION: Normal esophagram with no evidence of stricture or narrowing.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: SOB
Diagnosed with PNEUMONIA,ORGANISM UNSPECIFIED
temperature: 98.8
heartrate: 64.0
resprate: 22.0
o2sat: 98.0
sbp: 103.0
dbp: 56.0
level of pain: 7
level of acuity: 3.0 | ___ with PMH myasthenia ___, afib w ICD, CAD s/p MI, CHF, ITP
s/p splenectomy p/w fever recorded at rehab. Patient was
admitted s/p mechanical fall from ___. For the past 3 days
has experienced fever up to ___, as well as chills and night
sweats at rehab.
# Fever: No clear source for the fevers at this time, has been
afebrile on the floor and in the ED. Cough is several weeks in
duration, does not seem acute in onset, and CXR does not show
PNA. Pt says he no longer has cough. Has some urinary hesitancy
and dribbling, has a history of BPH which is not currently being
treated, this could increase static urine in the bladder and
increase risk of urinary tract infection - However, UA was
negative. No skin lesions, no n/v, no diarrhea, has
constipation. ED blood cultures were negative x2. Afebrile
during his admission. Being discharged off all antibiotics.
# Cough: Chronic cough, however, in light of fevers and no other
obvious infectious source (see above), we will treat for a
bronchitis with Azitromycin x5days. Also given cough syrup.
Treated with Azithromycin x5d, cough improved.
# Dysphagia: H/o esophogeal spasms and dysmotility issues on
previous esophogeal manometry. Pt states that he gets chest
pressure at the sternum when eating (ACS ruled out this
admission, neg EKG/enzymes), feels like food gets stuck,
worsening over last ___ weeks. Will order barium swallow and if
grossly abnormal, will order manometry +/- EGD. Barium swallow
was negative. Dysphagia may be related to Myasthenia ___,
___ order IVIG x3days, spoke with his Neurologist who agreed
with plan. Pt recieved 3days of IVIG (see below).
# CHF, EF 40%, CAD s/p CABG, HTN, HLD: The patient has been
complaining of atypical chest pain, which is associated with
eating/dysphagia, he says this is at baseline. Trops/CKMB
negative. Improved with home Lasix ___. EKG is stable. Volume
status was assessed and pt was appropriately treated while
recieveing IVG. Home meds were continued.
# Afib s/p AICD/PPM: Paced, continued ASA, dabigatran.
# Myasthenia ___: No current flare at time of admission.
Prednisone and Mycophenolate was continued. Spoke with
Neurologist who agreed that a course of IVIG for his MG could
help with current symptoms. Pt was observed and monitored for
flash pul edema during IVIG tx. He was premedicated with
Benadryl/Tylenol before each IVIG tx. Recieved IVIG over 3 days
(total 225gm) at a slower rate in order to avoid volume overload
(i.e. ___ hours). Pt tolerated tx. After tx, pt was feeling
somewhat better.
# Lupus anticoagulant c/b DVT/PE: Continued home dabigatran and
ASA.
# Chronic Back Pain/Spinal Stenosis: The patient also has R hip
pain and L shoulder pain left over from fall before recent
admission. Acute exacerbation of chronic pain. No fx on imaging
during last hospital stay. Seen and evaluated by ___ who
recommended d/c to home with home ___. Dilaudid ___ ___ q4h prn
pain was continued during his stay (discharged on this regimen
after last admission). Pt will be discharged with Dilaudid ___,
___ need close outpt management with PCP. |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Bactrim / Keflex / Catapres / Trazodone / Levaquin in D5W /
Colchicine / Fluoxetine / Lexapro / Lisinopril / metformin /
gabapentin
Attending: ___
___ Complaint:
chest pain and dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ woman, MI c/p PCI (___), CHF (EF
34%), VT s/p ICD, COPD, two prior early-stage lung
adenocarcinomas s/p resection now with metastatic
poorly-differentiated NSCLC with recent progression through
first-line on palliative carboplatin/pemetrexed p/w chest pain
and dyspnea.
Ms. ___ describes her pain as dull, constant pressure on her
right chest without radiation that started yesterday afternoon.
The pain worsened over the night and through this morning. She
endorses a slight increase in SOB which has made her sleeping
more uncomfortable. Her symptoms are quite severe, and she could
not get out of bed. She also notes that her appetite has
decreased in the past few weeks and she has had decreased PO.
Her recent restaging scans on ___ showed enlarging right
hilar mass causing severe narrowing of the RUL anterior
segmental pulmonary artery and superior right pulmonary vein
with moderate compression of the right superior and right middle
lobe bronchi. Patient also endorses some nausea after she eats,
but this has been chronic for years. Patient also endorses a
recent upper respiratory illness x 4 days with some rhinorrhea,
mild headache.
In the ED, initial vitals: 98.6 120 90/43 22 96% on RA.
Labs notable for: chem7 with K 3.2 and BUN/Cr ___ (baseline
1.2-1.3), CBC H&H 10.9/33.8 (at baseline).
She was given full dose ASA 325mg, heparin bolus and gtt for
presumed PE, 2L NS, digoxin 0.125mg, metoprolol 2.5mg IV x1,
morphine 5mg IV x1, albuterol neb x1, lorazepam 1mg x1.
Imaging: CXR with left midlung and retrocardiac opacity that
could be layering effusion or atelectasis/consolidation. CTA
with no e/o PE and mass stable for prior CT on ___.
On transfer, vitals were: 98 86 100/67 46 on NC. Patient is
complaining chest pain ___, and mild dyspnea, nausea. Denies
fevers, chills, abdominal pain, pedal edema, calf pain,
diarrhea.
Review of systems:
(+) Per HPI
Past Medical History:
Cardiac Risk Factors: Diabetes, Dyslipidemia, Hypertension
1. Coronary ___ disease, status post inferoposterior lateral
MI in ___, status post stent in the left circumflex and two
stents in the right coronary artery with a known chronically
occluded right coronary artery.
2. Carotid stenosis status post left carotid stent placement by
Dr. ___.
3. Hypertension.
4. Hyperlipidemia.
5. Type 2 diabetes.
6. Ischemic cardiomyopathy with EF of 30%.
7. History of ischemic mitral regurgitation.
8. History of ventricular tachycardia, status post ICD placement
in ___, generator change in ___.
9. An 80-pack-year history of tobacco, quit ___ years ago.
10. COPD.
11. Lung cancer status post left lobectomy with a new lung
nodule on the right. Per patient, she had recently seen her
oncologist, Dr. ___ confirmed the stability of the
lung nodule and feels that she is okay to follow up within one
year.
Social History:
___
Family History:
Father died of MI at ___ yo. Mother had CVA at ___ yo. 2 sister,
both healthy.
Physical Exam:
ADMISSION
Vitals: T: 98 BP: 101/56 P: 82 R: 12 O2: 92% RA
GENERAL: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: Decreased air movement bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 S2, III/VI systolic
murmur, rubs, gallops
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
ADMISSION
___ 10:20AM BLOOD WBC-8.6 RBC-3.75* Hgb-10.9* Hct-33.8*
MCV-90 MCH-29.1 MCHC-32.2 RDW-18.5* RDWSD-60.7* Plt ___
___ 10:20AM BLOOD Glucose-175* UreaN-28* Creat-1.2* Na-139
K-3.2* Cl-98 HCO3-24 AnGap-20
___ 10:20AM BLOOD ALT-24 AST-17 AlkPhos-101 TotBili-0.5
___ 10:20AM BLOOD proBNP-3697*
___ 10:20AM BLOOD cTropnT-0.02*
___ 10:20AM BLOOD Digoxin-0.5*
___ 10:20AM BLOOD Albumin-3.6
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 325 mg PO DAILY
2. Atorvastatin 80 mg PO DAILY
3. Bisacodyl 20 mg PO QOD:PRN constipation
4. Clopidogrel 75 mg PO DAILY
5. Colchicine 0.6 mg PO QOD
6. Digoxin 0.125 mg PO EVERY OTHER DAY
7. Febuxostat 80 mg PO DAILY
8. Fluticasone Propionate NASAL 2 SPRY NU DAILY
9. Furosemide 60 mg PO DAILY
10. Levothyroxine Sodium 150 mcg PO DAILY
11. Lorazepam 0.5 mg PO BID:PRN anxiety, insomnia
12. Losartan Potassium 75 mg PO DAILY
13. Metoprolol Tartrate 100 mg PO BID
14. Pantoprazole 40 mg PO Q12H
15. Sertraline 125 mg PO QAM
16. Spironolactone 12.5 mg PO DAILY
17. Tiotropium Bromide 1 CAP IH DAILY
18. Acetaminophen 650 mg PO Q6H
19. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing
20. bifidobacterium infantis 4 mg oral daily
21. GlyBURIDE 5 mg PO BID
22. melatonin 3 mg oral qhs
23. Nitroglycerin SL 0.3 mg SL PRN chest pain
24. Senna 8.6 mg PO BID:PRN constipation
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing
3. Aspirin 325 mg PO DAILY
4. Atorvastatin 80 mg PO DAILY
5. Bisacodyl 20 mg PO QOD:PRN constipation
6. Clopidogrel 75 mg PO DAILY
7. Colchicine 0.6 mg PO QOD
8. Digoxin 0.125 mg PO EVERY OTHER DAY
9. Febuxostat 80 mg PO DAILY
10. Fluticasone Propionate NASAL 2 SPRY NU DAILY
11. Levothyroxine Sodium 150 mcg PO DAILY
12. Metoprolol Tartrate 100 mg PO BID
13. Nitroglycerin SL 0.3 mg SL PRN chest pain
14. Pantoprazole 40 mg PO Q12H
15. Senna 8.6 mg PO BID:PRN constipation
16. Sertraline 150 mg PO DAILY
17. Tiotropium Bromide 1 CAP IH DAILY
18. Furosemide 40 mg PO DAILY
RX *furosemide 40 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
19. bifidobacterium infantis 4 mg oral daily
20. GlyBURIDE 5 mg PO BID
21. melatonin 3 mg oral qhs
22. Ondansetron 8 mg PO Q8H:PRN nasea
RX *ondansetron 8 mg 1 tablet(s) by mouth q8h prn Disp #*30
Tablet Refills:*0
23. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth q4h prn Disp #*50
Tablet Refills:*0
24. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 17 gram/dose 1 powder(s) by mouth
daily Refills:*0
25. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
26. ClonazePAM 0.5 mg PO TID
RX *clonazepam 0.5 mg 1 tablet(s) by mouth three times a day
Disp #*50 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnoses:
Hypotension
Atrial fibrillation
Secondary diagnosis:
Metastatic non small cell lung cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ with chest pain, shortness of breath // eval for
pneumothorax, pneumonia, PE
TECHNIQUE: Single portable view of the chest.
COMPARISON: ___.
FINDINGS:
There is a large right paramediastinal mass abutting the hilum as seen on
prior. There is also a pleural-based mass projecting over the right mid to
lower lung also seen on prior. New from prior is hazy left mid lung and
retrocardiac opacity. Left chest wall pacing device is again noted.
IMPRESSION:
Known right hilar and right pleural based mass as on prior.
Hazy left mid lung and retrocardiac opacity could represent a layering
effusion or potentially atelectasis/ consolidation. Consider PA and lateral
to further assess.
Radiology Report
EXAMINATION: CTA CHEST WANDW/O CANDRECONS, NON-CORONARY
INDICATION: ___ with chest pain, shortness of breath // eval for
pneumothorax, pneumonia, PE, increasing lung mass
TECHNIQUE: Axial multidetector CT images were obtained through the thorax
after the uneventful administration of 100 cc of Omnipaque intravenous
contrast.
Reformatted coronal, sagittal, thin slice axial images, and oblique maximal
intensity projection images were submitted to PACS and reviewed.
DOSE: Total DLP (Body) = 397 mGy-cm.
COMPARISON: Chest CT from ___.
FINDINGS:
Aorta and great vessels are unremarkable without dissection or aneurysm. The
pulmonary arteries are well opacified to the subsegmental level without
filling defect to suggest pulmonary embolism. There is however is significant
attenuation of the right-sided pulmonary arterial tree particularly to the
right upper lobe. Right middle lobe pulmonary arterial segmental branch is
also significantly attenuated by the mass with decreased opacification
distally (3:90, 91).
Heart size is normal. Coronary artery and aortic root calcifications are
noted. Atherosclerotic calcifications are also noted throughout the aorta and
great vessels. There is a small pericardial effusion.
Large mass centered at the right hilum and paramediastinal region is again
noted. It measures approximately 7.5 cm AP x 5.7 cm TRV, previously 7.0 x 4.7
cm when measured in similar ___. Narrowing of the pulmonary arterial
branches is as detailed above. There is also narrowing of the right superior
pulmonary vein. Peribronchial wall thickening distal to the mass particularly
involving the right upper lobe is unchanged. Pleural based/chest wall mass
between the anterior right fourth and fifth ribs is again seen measuring 4.4 x
3.5 cm, not significantly changed.
The left lung is clear without consolidation, effusion or pneumothorax. Small
pulmonary nodule (03:44) in the superior segment of the left lower lobe is
unchanged. Patient is status post left upper lobectomy. Finding of increased
opacity in the left hemi thorax on same-day chest x-ray was likely technical.
Right upper lobe wedge resection changes are also noted.
Limited images of the upper abdomen are notable for a partially visualized
right adrenal nodule which is unchanged from prior.
No suspicious osseous lesions identified. There is no acute fracture.
Chronic left lateral rib fractures are noted.
IMPRESSION:
1. No pulmonary embolism or acute aortic abnormality.
2. Large right paramediastinal/hilar mass minimally enlarged since exam from
___ with mass effect on adjacent structures as detailed above.
Right pleural based/chest wall mass grossly unchanged.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Dyspnea
Diagnosed with Chest pain, unspecified
temperature: 98.6
heartrate: 120.0
resprate: 22.0
o2sat: 96.0
sbp: 90.0
dbp: 43.0
level of pain: 0
level of acuity: 2.0 | Ms. ___ is a ___ woman, active smoker, MI c/p PCI
(___), CHF (EF 34%), VT s/p ICD, COPD, two prior early-stage
lung adenocarcinomas s/p resection now with metastatic
poorly-differentiated NSCLC with recent progression through
first-line on palliative carboplatin/pemetrexed p/w chest pain
and dyspnea.
# Metastatic NSCLC: Recent progression through first-line
palliative carboplatin/pemetrexed. Decided to proceed with
palliative nivolumab after discussion with primary oncologist.
Pt remains DNR/DNI and will have her ICD deactivated. Palliative
___ is consulted for aid with symptom control and support with
prognosis. Patient has significant anxiety related to her
prognosis and her anxiolytic regimen was changed to
longer-acting diazepam. Follow up appointment with heme/onc
scheduled for ___.
# Chest pain/dyspnea: Most likely d/t mass effect of her
advancing cancer based on findings on imaging. CTA negative for
PE. Pain was managed with oxycodone ___ and Tylenol. We stopped
her heparin gtt and switched her to SQ heparin for DVT
prophylaxis.
# Hypotension: Resolved after 2 L of NS in ED. Likely secondary
to decreased PO in the setting of various anti-hypertensives and
diuretics. Good urine output, stable creatinine.
# CAD s/p PCI: Continued atorva, clopidogrel, ASA.
# CHF: EF 34% based on TTE in ___. BNP 3697. Restarted
diuresis at 40mg PO given poor PO intake, continued digoxin.
Given patient's prognosis and DNR/DNI status, EP was consulted
to deactivate ICD after discussion with patient and family.
# COPD: cont. home meds
# HTN: held home anti-hypertensives initially in setting of
hypotension.
# HLD: cont. home statin
# DMII ISS while in house
# Depresison/Anxiety: Continue Sertraline, Increase Lorazepam
to q6h
# Hypothyroidism: Continue Levothyroxine
# Gout: Continue Colchicine and Febuxostat
# Goals of ___: palliative ___ consulted while in the FICU. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
esophageal impaction
Major Surgical or Invasive Procedure:
Esophagogastroduodenoscopy
History of Present Illness:
This is a ___ year-old Male with a PMH significant for
esophageal achalasia (diagnosed in the ___, trialed CCBs and
nitrates; s/p three prior Botox injections following food
impaction, s/p esophageal myotomy at ___ in ___ who now
presents with 7-days of acute onset crampy abdominal pain,
nausea
with emesis and loose, non-bloody stools associated with
odynophagia to solids and liquids.
.
The patient initially awoke 7-days prior with acute onset ___
crampy abdominal pain in a band-like distribution, without
radiation that has been intermittent; associated with nausea and
food particulate and bilious emesis episodes. He also had a few
episodes of loose, watery and non-bloody stools. He denies
fevers
or chills. Over the course of several days he started to note
odynophagia to solids and liquids, without inciting factor. He
notes no identifiable foods that precipitate his achalasia
flares. He notes some decreased PO intake over the last several
days, without weight loss (stable at 163-lbs). He was seen at
___ and Dr. ___ recommended
against endoscopy. He was transferred to ___ for further
management. He is passing flatus and his last BM was formed
yesterday. His nausea, emesis and diarrhea has resolved, only
his
abdominal discomfort remains. He denies sick contacts, recent
travel or recent antibiotic use. No globus sensation, no
regurgitation or hiccups.
.
In the ___ ED, initial VS 98.7 80 ___ 97% RA. A chest
radiograph showed large particulate filled structure adjacent to
the right heart border consistent with a markedly distended
esophagus filled with residual ingested material. He received 1L
NS x 1. His laboratory studies were only remarkable for a
normocytic anemia to 27.3% on admission. He was reportedly
guaiac
positive at ___.
Past Medical History:
1. Esophageal achalasia (diagnosed in the 1990s, initially
medically managed with CCBs and nitrates; three prior Botox
injections - two performed in ___ and ___ following
endoscopy at ___ and one at ___ s/p surgical
myotomy in ___ at ___
2. Grade III esophagitis (treated with Omeprazole in ___
Social History:
___
Family History:
Niece with ulcerative colitis. No other family history of GI
malignancy (colon, stomach cancer).
Physical Exam:
Vitals: 97.2 100/60 66 18 96/RA
GENERAL - well-appearing male lying in bed in NAD, comfortable,
appropriate
HEENT - NC/AT, PERRL, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - Right sided vesicular breath sounds posteriorly over
middle of right lung, otherwise CTA w/ good air mvmt.
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact
Pertinent Results:
Admission labs:
___ 09:00PM GLUCOSE-89 UREA N-10 CREAT-0.7 SODIUM-140
POTASSIUM-4.0 CHLORIDE-107 TOTAL CO2-25 ANION GAP-12
___ 09:00PM WBC-6.4 RBC-2.95* HGB-8.9* HCT-26.0* MCV-88
MCH-30.3 MCHC-34.4 RDW-13.6
___ 09:00PM NEUTS-63.6 ___ MONOS-4.3 EOS-1.6
BASOS-0.3
___ 09:00PM PLT COUNT-469*
___ 09:00PM ___ PTT-27.1 ___
___ 08:26PM GLUCOSE-93 UREA N-10 CREAT-0.8 SODIUM-139
POTASSIUM-4.2 CHLORIDE-104 TOTAL CO2-27 ANION GAP-12
___ 08:26PM estGFR-Using this
___ 08:26PM WBC-6.7 RBC-3.10* HGB-9.5* HCT-27.3* MCV-88
MCH-30.7 MCHC-34.9 RDW-13.5
___ 08:26PM NEUTS-65.0 ___ MONOS-4.6 EOS-1.5
BASOS-0.3
___ 08:26PM PLT COUNT-457*
___ 08:26PM ___ PTT-27.1 ___
Discharge Labs:
___ 06:50AM BLOOD WBC-6.4 RBC-2.95* Hgb-9.0* Hct-25.8*
MCV-88 MCH-30.5 MCHC-34.8 RDW-13.5 Plt ___
___ 06:50AM BLOOD Ret Aut-6.0*
___ 06:50AM BLOOD Glucose-125* UreaN-8 Creat-0.6 Na-137
K-3.4 Cl-103 HCO3-27 AnGap-10
___ 06:50AM BLOOD LD(LDH)-116 TotBili-0.2 DirBili-0.0
IndBili-0.2
___ 06:50AM BLOOD Calcium-7.9* Phos-3.6 Mg-2.3 Iron-43*
___ 06:50AM BLOOD calTIBC-278 Ferritn-23* TRF-214
CXRay:
FINDINGS: PA and lateral views of the chest were obtained. There
is marked
mediastinal widening which extends into significant portion of
the right
hemithorax. In this patient with provided history of achalasia,
findings are concerning for esophageal impaction. There is no
evidence of aspiration. No large pleural effusion is seen. No
pneumothorax. Heart size is difficult to assess. Bony structures
appear intact.
IMPRESSION: Findings concerning for esophageal impaction within
a markedly
dilated esophagus.
.
EGD:
Impression:
Large quantities of solid and liquid food in massively dilated
esophagus.
Cobblestoning of the whole esophagus
Normal mucosa in the stomach
Normal mucosa in the duodenum
The GE junction was able to be traversed easily with
colonoscope.
Otherwise normal EGD to third part of the duodenum
Recommendations:
Follow-up biopsy results
Recommend Surgery consult to evaluate for repeat Myotomy vs.
esophagectomy.
Manometry can be considered and if the resting pressures are
high at the LES, repeat Myotomy can be considered.
Recommend full liquid diet until the Achalasia is treated.
Medications on Admission:
MVI
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnoses: Achalasia, massive esophageal dilatation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
CHEST RADIOGRAPH PERFORMED ON ___
COMPARISON: None.
CLINICAL HISTORY: ___ man with achalasia, presents with chest pain,
assess for esophageal impaction.
FINDINGS: PA and lateral views of the chest were obtained. There is marked
mediastinal widening which extends into significant portion of the right
hemithorax. In this patient with provided history of achalasia, findings are
concerning for esophageal impaction. There is no evidence of aspiration. No
large pleural effusion is seen. No pneumothorax. Heart size is difficult to
assess. Bony structures appear intact.
IMPRESSION: Findings concerning for esophageal impaction within a markedly
dilated esophagus.
Gender: M
Race: UNKNOWN
Arrive by UNKNOWN
Chief complaint: FOOD IMPACTION
Diagnosed with ABDOMINAL PAIN EPIGASTRIC, ACHALASIA & CARDIOSPASM
temperature: 98.7
heartrate: 80.0
resprate: 16.0
o2sat: 97.0
sbp: 112.0
dbp: 72.0
level of pain: 7
level of acuity: 3.0 | ___ M with pmhx of achalasia s/p failed CCB and nitrate trials,
multiple botox injections, and surgical myotomy at ___ in ___
presents with with 10-days of acute onset crampy abdominal pain,
nausea with emesis and loose, non-bloody stools associated with
odynophagia to solids and liquid. The patient was found to have
esophageal impaction from his achalasia and most likely had a
preceding viral gastroenteritis.
.
# Esophageal impaction from achalasia: The patient's symptoms of
unresolving abdominal pain with worsening on food intake and
odynophagia were due to the patient's achalasia and esophageal
impaction. This was treated during EGD via aspiration of the
esophageal contents. Diffuse cobblestoning was present
throughout the esophagus. Biopsies were taken. It was
recommended that the patient be assessed for repeat myotomy
versus esophagectomy. The patient had previously responded
extremely well to myotomy without symptoms since the ___
procedure. There was no urgent need for intervention after the
EGD and the patient preferred to have a second opinion regarding
further workup from his physicians at ___. The patient was thus
discharged with instructions to maintain a full liquid diet as
solids were likely to just reaccumulate until the achalasia is
treated. Biopsy results will be followed and communicated to
Dr. ___.
.
# Viral gastroenteritis: Pt had a few episodes of emesis with
nausea and diarrhea approximately 10 days ago which resolved
over the course of two days. This was most likely a
self-limited viral GI illness.
.
# Normocytic Anemia: The pt was reportedly guaiac positive at
OSH. He was found to have a normocytic anemia with negative
hemolysis labs, low ferritin and iron, and normal TIBC and
Transferrin. The patient reported being anemic in past when he
had an esophageal ulcer but this had resolved and his counts
returned to ___ after ferrous sulfate. We recommend a
colonscopy as an outpatient.
.
.
# CODE: full code
# CONTACT: mother ___ ___
.
TRANSITIONAL: Follow up biopsy results. Needs to follow up with
Dr. ___ achalasia treatment. Colonscopy as
outpatient. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Ativan / Compazine
Attending: ___.
Chief Complaint:
hematemesis
Major Surgical or Invasive Procedure:
EGD x3 with clipping
History of Present Illness:
___ yo F h/o HTN, sCHF, bleeding gastric ulcer s/p partial
gastrectomy ___, sarcoidosis, afib not on coumadin, hematemesis
with anastamotic ulcer on EGD in ___ p/w nausea and vomiting
last night. She was in her usual state of health during the
day, went out for ___ food for dinner around 5 pm.
Initially felt well afterwards, around 10 pm felt nauseated and
started vomiting. Was up all night with abdominal pain and
nausea, vomited about five times last night. This morning
around 6 am vomited bright red blood. Not sure how much it was,
no coffee grounds. Also may have had a dark stool this AM but
she is not sure. Denies any diarrhea currently, but had
diarrhea last week. She does get nauseated about once a week,
used to be followed in GI clinic for this and was thought to be
related to GERD and possible ulcer disease, has been on a BID
PPI and PRN promethazine at home, takes promethazine about
weekly. Unable to take last night due to nausea. No h/o liver
disease. No h/o liver disease. Denies chest pain, shortness of
breath, lightheadedness, joint pain, rashes, sick contacts.
.
In the ED, initial VS were HR 82, BP 162/98, RR 14, sat 99% 3L
NC. EKG showed sinus rhythm 82 bpm, prolonged PR interval, PVCs
and new lateral ST depressions. Pt given IV NS, protonix 80 mg
bolus and started on drip, zofran 4 mg, and morphine. Pt
appeared dry on exam, rectal exam with no stool in the vault.
NG lavage not done given presence of bright red blood in vomit.
Hct 36 so no blood products were given, coags wnl. Access with
PIV x 2. Received 2.5 L of IV NS. GI called from ___,
recommended EGD. Admitted to ICU for active vomiting of blood
noted in ED. VS on transfer temperature 97.8. HR 86 RR 20 BP
152/81, afib, sat 100% 2L.
.
On arrival to ICU, pt feels nauseated and abdominal pain in
lower part of abdomen which started last night as well,
nonradiating, feels like cramping. No fever since episodes
started but did have a fever to 101 about 2 weeks ago for which
she was treated with amoxicillin. Has had 4 episodes total of
blood in vomit, although unable to quantify amount of blood.
.
Review of systems:
(+) Per HPI, also + for cough for the last few weeks, recently
treated for presumed PNA with 10 day course of amoxicillin,
suspected that cough may be related to pulmonary sarcoidosis per
daughter
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies shortness of breath, or wheezing. Denies
chest pain, chest pressure, palpitations, or weakness. Denies
constipation. Denies dysuria, frequency, or urgency. Denies
arthralgias or myalgias. Denies rashes or skin changes.
Past Medical History:
1. HTN
2. Hypercholesterolemia
3. systolic CHF, etiology unclear
4. Bleeding gastric ulcer s/p partial gastrectomy in ___.
5. Hematemesis ___ years ago. No source was found on EGD.
6. Lap cholecystetomy in ___ complicated by liver laceration
and PE
7. Post-op PE requiring brief intubation and s/p IVC filter and
anticoagulation in ___
8. S/p appendectomy
9. Iron deficiency anemia
10. OA of left knee requiring knee replacement
11. S/p fall complicated by displacement of anterior arch of C1
one year ago; wore hard collar for one year and is now s/p
surgical fixation in ___ at ___
12. L TKR due to non ___ of femur fx ___ at OSH
13. h/o depression
14. atrial fibrillation
15. hematemesis bleeding ulcer noted at ___ II anasthamosis
in ___ (gastrin level wnl and H. pylori negative)
16. sarcoidosis dx ___ with pulmonary symptoms and lymph node
bx
Social History:
___
Family History:
Her father died of renal cancer; brother with lung cancer; no hx
of CAD; no hx of colon cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 98.7 HR 86 BP 143/74 sat 97% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, tacky mucous membranes, no
oropharyngeal lesions
Neck: supple, JVP not elevated, no LAD
Lungs: crackles at bases bilaterally, no wheezes, rhonchi
CV: Regular rate and rhythm, normal S1 + S2, III/VI systolic
murmur best heard at apex
Abdomen: soft, mild ttp throughout, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
___ 07:05AM BLOOD WBC-15.5* RBC-4.02* Hgb-11.7* Hct-36.9
MCV-92 MCH-29.1 MCHC-31.6 RDW-14.9 Plt ___
___ 12:55PM BLOOD WBC-10.6 RBC-2.90*# Hgb-8.7*# Hct-26.4*#
MCV-91 MCH-29.9 MCHC-32.9 RDW-15.0 Plt ___
___ 07:25PM BLOOD Hct-24.0*
___ 02:53AM BLOOD WBC-14.9* RBC-3.22* Hgb-9.6* Hct-28.8*
MCV-89 MCH-29.9 MCHC-33.5 RDW-14.8 Plt ___
___ 09:22AM BLOOD Hct-26.0*
___ 03:30PM BLOOD Hct-28.9*
___ 04:24AM BLOOD WBC-8.6 RBC-2.66*# Hgb-8.1*# Hct-23.6*#
MCV-89 MCH-30.3 MCHC-34.2 RDW-14.8 Plt Ct-84*
___ 07:05AM BLOOD ___ PTT-29.9 ___
___ 04:59AM BLOOD ___ PTT-29.2 ___
___ 07:05AM BLOOD ___ 07:05AM BLOOD Glucose-159* UreaN-17 Creat-0.7 Na-140
K-4.3 Cl-102 HCO3-25 AnGap-17
___ 02:53AM BLOOD Glucose-124* UreaN-25* Creat-0.6 Na-141
K-3.8 Cl-110* HCO3-22 AnGap-13
___ 04:24AM BLOOD Glucose-67* UreaN-21* Creat-0.5 Na-141
K-3.6 Cl-112* HCO3-21* AnGap-12
___ 07:05AM BLOOD ALT-20 AST-43* LD(LDH)-432* AlkPhos-120*
TotBili-0.3
___ 02:53AM BLOOD ALT-14 AST-24 AlkPhos-77
___ 07:05AM BLOOD Lipase-19
___ 07:05AM BLOOD Calcium-9.4 Phos-4.3 Mg-1.8
___ 02:53AM BLOOD Calcium-7.1* Phos-2.5* Mg-1.9
___ 04:24AM BLOOD Calcium-6.5* Phos-2.6* Mg-1.7
___ 03:10AM BLOOD Digoxin-0.5*
___ 04:34AM BLOOD freeCa-1.00*
___ 08:00AM URINE Color-Yellow Appear-Clear Sp ___
___ 08:00AM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-TR
___ 08:00AM URINE RBC-2 WBC-1 Bacteri-NONE Yeast-NONE
Epi-<1
MICRO:
Urine (___): no growth
EKG (___): Rate 82. Sinus rhythm. First degree A-V block.
Leftward axis. Poor R wave progression. Lateral ST-T wave
abnormalities. Compared to the previous tracing of ___ first
degree A-V block is now present.
CXR (___):
IMPRESSION:
1. No evidence of intra-abdominal free air.
2. Stable cardiomegaly.
3. No evidence of decompensated congestive heart failure or
pneumonia.
Hand (___) Xray:
PND
EGD ___:
Impression: Normal mucosa in the esophagus
Blood in the stomach body
Dieulafoy lesion in the Anastomotic site (endoclip)
Both the limbs were identified and no source of bleeding was
noticed in those.
Otherwise normal EGD to third part of the duodenum
Medications on Admission:
alendronate 70 qweek
atenolol 25mg qam 50 qpm
dig 0.125 qd
lidoderm patch for back or knee
lisionpril 30mg qday
omeprazole 20mg bid
pravastatin 40mg qd
ropinirole 1mg qhs
effexor 150 mg qd
vit d
-allergies: ativan, compazine and advair
Discharge Medications:
1. pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. ropinirole 1 mg Tablet Sig: One (1) Tablet PO QPM (once a day
(in the evening)).
4. venlafaxine 75 mg Capsule, Ext Release 24 hr Sig: Two (2)
Capsule, Ext Release 24 hr PO DAILY (Daily).
5. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
6. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
7. atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day.
8. lisinopril 30 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Upper GI bleed due to gastric ulcer
Acute blood loss anemia
Atrial fibrillation
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
INDICATION: Hematemesis, evaluate for intra-abdominal free air.
COMPARISONS: Chest radiograph from ___.
PORTABLE UPRIGHT RADIOGRAPH OF THE CHEST: The underinflated lungs are clear.
There is stable moderate cardiomegaly. There is no pneumothorax or pleural
effusion. There is bibasilar atelectasis. The pulmonary vascularity is
normal.
There is no evidence of intra-abdominal free air. Surgical clips are noted in
the right upper quadrant, consistent with probable prior cholecystectomy.
There is S-shaped scoliosis of the thoracic spine.
IMPRESSION:
1. No evidence of intra-abdominal free air.
2. Stable cardiomegaly.
3. No evidence of decompensated congestive heart failure or pneumonia.
Radiology Report
STUDY: Three views of the bilateral hands ___.
COMPARISON: Bilateral radiographs ___.
INDICATION: Question rheumatoid arthritis. Hand swelling.
FINDINGS:
RIGHT HAND: Mild dorsal soft tissue swelling. Unchanged subluxation and
degenerative changes of the index and long finger and MCP joint and thumb CMC
joint. No definite fracture. No dislocation. IV tubing is noted across the
distal forearm.
LEFT HAND: IV tubing overlies the hand. Mild dorsal soft tissue swelling.
Unchanged degenerative changes of the ring finger PIP joint and index and long
finger MCP joints and thumb CMC joint. No fracture or dislocation.
IMPRESSION: No significant interval change.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: GI BLEED
Diagnosed with GASTROINTEST HEMORR NOS
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: nan | BRIEF HOSPITAL COURSE:
___ yo F h/o HTN, sCHF, bleeding gastric ulcer s/p partial
gastrectomy ___, hematemesis in ___ anastamotic bleed,
afib not on coumadin p/w nausea and vomiting, hematemesis
.
ACTIVE ISSUES:
# Hematemesis/Acute blood loss Anemia: Patient was initially
admitted to the ICU for frequent episodes of hematemesis with
stable blood pressures and heart rate in the ED. Initially Hct
was 36 in setting of dehydration and decreased to 26 after fluid
repletion. GI was consulted and EGD was done on day of
admission which showed likely Dieulafoy's lesion near
anastatmotic site from prior gastric bypass surgery, and three
clips were placed. Followup Hct was 24 after EGD, transfused 2
units of PRBC. She was scoped again the following day which
again showed bleeding Dieulafoy lesion and 2 clips were placed
and lesion injected. Followup Hct suggested continued bleeding
so she was transfused 2 more units PRBC. Third EGD was done on
___ which showed no bleeding at anastamotic site and areas
suggestive of ischemia around the anastamotic site. Patient was
evaluated by the surgical team who recommended no acute
intervention and transfusion goal of Hct >30 and platelets >70,
___ was made aware of patient who recommended no acute
intervention. Throughout course in MICU patient's blood
pressure, urine output remained stable and patient was continued
on protonix 40 mg IV BID. She received total of 6 units PRBC in
MICU and antihypertensives were held. Her Hct remained stable
and she was transitioned to orals. H. pylori was also sent and
was negative.
.
# Afib: Pt history with atrial fibrillation, not on coumadin.
At home she is on rate control with atenolol and on digoxin,
however this was held in setting of acute bleed. She had one
episode of afib w/ RVR to 140s ___ around the EGD procedure.
The patient was given 2.5mg metoprolol IVx2 and 5mg IV x1. Pt
was otherwise in sinus during MICU stay. Her digoxin was
continued. Her beta blocker was started as Metoprolol on ___,
and she remained stable. Aspirin is being held in light of GI
bleeding.
.
#Hand pain/ swelling: Patient has chronic pain at baseline, on
___ noted to have swollen and tender MCP joints. Pt with
history of sarcoidosis and inflammatory appearance of joints,
started short course of prednisone 20 mg x 4 days and standing
tylenol. Pseudogout was also a consideration. Hand xrays
ordered and showed nothing acute.
.
# Nausea/vomiting/abd pain: Pt has had episodes in the past of
nausea and vomiting usually post-prandial and is on PPI BID as
symptoms thought to be ___ GERD or recurrence of ulcers in the
past, viral gastroenteritis was also on differential. It is
possible that symptoms were also related to lesion at
anastamotic site. Zofran and IV morphine given with symptomatic
improvement. This was transitioned to oral oxycodone, and then
this was weaned because of fall risk. Abdominal exam remained
benign.
# leukocytosis: Initally WBC 15.5, improved without
intervention. ___ have been in setting of stress vs
gastroenteritis given sx of nausea, vomiting. No fevers during
stay in MICU, but was recently treated for cough and fever with
amoxicillin.
# Cough: has been ongoing for about 2 weeks, no change with
antibiotics and CXR with no acute process making PNA or CHF exac
less likely. ___ be related to viral bronchitis vs re-occurance
of sarcoidosis (had pulmonary sarcoid in the past, follows in
pulmonology). Being worked up as outpatient
# HTN: Held atenolol, lisinopril in setting of acute bleed.
Restarted low dose BB first on ___. ACE-I held and restarted
at a lower dose (10mg daily, instead of 30mg daily). Should be
revaluated by PCP.
.
# chronic pain: pt with chronic pain in setting of multiple knee
and neck surgeries. She is on an oxycodone regimen per her PCP,
received IV morphine in ICU since pt had increased pain and was
NPO. I did not give her more oxycodone since this increases
risk of falls, and she at times felt light-headed after taking
it when walking with walker (though proved to be stable on
evaluation). she was instructed not to drive on this medication.
# chronic systolic CHF: She appeared euvolemic on exam. Most
recent EF is 50% from dobutamine stress test. Beta blocker and
ACEI held in setting of bleed, but restarted gradually once her
bleeding resolved.
# depression: continued effexor
# Communication: Patient, daughter/hcp ___ ___
home: ___
# Code status: DNR, ok to intubate |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
alendronate sodium
Attending: ___.
Chief Complaint:
N/V, mechanical fall
Major Surgical or Invasive Procedure:
Therapeutic paracentesis on ___
Nasogastric tube placement on ___
History of Present Illness:
Ms. ___ is a ___ woman with metastatic serous carcinoma
of likely GYN origin presenting with abdominal pain,
nausea/vomiting, and a mechanical fall.
She reports that for ___ days prior to admission, she was having
abdominal pain and constipation (no bowel movement x4 days). She
was taking limited p.o. over that time. She describes a band of
pain like "twisting intestines" that is pulsatile/intermittent.
There are no obvious aggravating or alleviating factors.
The night prior to admission (___) she developed nausea and had
a small bout of emesis; the morning of admission she had emesis
again of the food she had eaten. No blood noticed. She
subsequently slipped in her own emesis with a head strike (no
loss of consciousness). She did not have any new neurologic
symptoms.
She has had no fevers or chills.
In the ED, initial vitals were: 98.4 | 87 | 108/60 | 18 | 100%
RA
Labs were notable for:
9.2 > 11.1/36.1 < 205 (MCV 105)
142 | 100 | 28 Ca 9.1
--------------< 144 Mg 1.8
3.4 | 29 | 1.2 P 3.7
AST/ALT ___, AP 55, Tbili 0.5, Alb 3.8
___ 11.2, ___ 24.7, INR 1.0
Lactate 1.3
UA bland but for protein and 10 ketones
Imaging performed included:
# CT A/P with contrast:
1. Short segment of small bowel wall thickening and wall edema
in the mid abdomen with few fluid filled loops of small bowel,
most compatible with enteritis.
2. Redemonstration of large volume ascites.
3. New ground-glass opacities in the right lower lobe. Correlate
clinically for aspiration or pneumonia.
4. Stable dilation of the main pancreatic duct and CBD without
obstructing lesion.
# CT C-spine without contrast:
1. No malalignment or fractures a sequela of trauma.
2. Stable multilevel degenerative changes worse at C5-C6 and
C6-C7 levels.
# CT Head without contrast:
1. No acute intracranial findings.
2. Paranasal sinus disease.
The patient was given:
500mg LR IV
40 mEq potassium
4 mg morphine IV
4 mg Zofran IV
1 g ceftriaxone IV
500 mg metronidazole IV
Vitals prior to transfer: 98.0 | 71 | 129/47 | 17 | 96% RA
Upon arrival to the floor, Ms. ___ confirmed the above story
with her son ___ (son ___ also at bedside).
REVIEW OF SYSTEMS: A complete 10-point review of systems was
performed and was negative except for as noted in the HPI. She
does also describe chronic increased urinary frequency and
intermittent incontinence that are long-standing.
Past Medical History:
PAST ONCOLOGIC HISTORY, per primary oncologist note:
Pt reported increasing bloating and abdominal pain beginning in
early ___ that worsened for a month. She was seen at
her PCP's office on ___ at which point TSH, albumin, LFTs were
drawn and were all within normal limits. She underwent an
abdominal ultrasound on ___ which showed large volume
ascites with peritoneal nodularity visualized within the pelvis
with concern for ovarian malignancy or other primary. She had a
follow up CT abdomen/pelvis on ___ which showed massive
ascites. Neither ovary were clearly visualized nor was the
appendix. Peritoneal nodularity seen on US was not clearly
identified though there was some mild hyperenhancement of the
inferior peritoneal surface just superior to the bladder.
She subsequently had a therapeutic paracentesis on ___ with
evacuation of 3L of fluid. Cytology report showed high grade
serous carcinoma with p53 showing mutant pattern staining.
She was seen by OB/GYN on at which point she noted the fluid
appeared to be recurring. ___ weight gain in the last 6mo.
She has a history of leg swelling for which she takes lasix 30mg
QD. She was recommended tumor markers including CA125, CEA, and
___ CT-Chest; diagnostic laparoscopy to assess disease
extent
which will likely be followed by chemotherapy with a possible
interval cytoreductive surgery including a total hysterectomy,
bilateral salpingo-oophorectomy, lymphadenectomy, omentectomy,
and removal of residual disease. Hearing this plan, pt expressed
interest in forgoing surgery.
At first oncology visit on ___, she explained her greatest
source of discomfort was abdominal pain/bloating. We recommended
CT chest to complete staging and a visit with OB/GYN to discuss
the role for surgical management of her disease.
___ C1D1 ___ AUC 2 (day 1, 15)
___ C2D1 ___ AUC 2 (day 1, 8)
___ C3D1 ___ AUC 2 (d1,8)
___ C4D1 ___ AUC 2 (d1, 15)
___ C5D1 ___ AUC 2 (d1, 15)
___ C6d1 ___ AUC 2 (d1, 15)
___ Break from chemotherapy; CA125 had plateaued and is
slightly increased today, indicating carboplatin resistance.
Scans overeall had improvd
PAST MEDICAL HISTORY:
- HTN
- HLD
- IgA/IgG pemphigus foliaceous (on cellcept and low dose
prednisone)
- Positive PPD, neg CXR - refused INH
- Chronic ___ edema
- Postherpetic neuralgia
- Low back pain - DJD on LS-spine XR ___
- Osteoporosis
- Plantar Fasciitis
- Cataracts
Social History:
___
Family History:
- no known history of breast, cervical, endometrial, uterine, or
colon CA
- no known history of bleeding or clotting disorder
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
VS: 97.9 | 120/80 | 87 | 18 | 96%RA
GENERAL: Cachectic and chronically ill-appearing woman,
nontoxic, no acute distress
HEENT: Normocephalic, atraumatic, approximately 3 x 3 cm area of
tenderness to palpation over posterior/temporal left region
(area of headstrike). No scleral icterus, no conjunctival
pallor. Dry mucous membranes. Poor dentition.
NECK: No concerning lymphadenopathy
CV: Regular rate and rhythm, systolic murmur best over left
sternal border
PULM: Breathing comfortably on room air, no accessory muscle
use, lateral fields clear
ABD: Distended, normoactive bowel sounds, tender to palpation
worse in the right upper quadrant; palpable ?Intestines vs. Mass
vs hepatomegaly to 4 fingerbreadths below costal margin. No
rebound or guarding.
EXT: Warm, well-perfused, no edema.
SKIN: No rashes/lesions. Umbilicus somewhat dry/crusted.
NEURO: Oriented to "hospital," city, ___ Attentive
to DOWB.
ACCESS: Right chest port, dressing c/d/i
DICHARGE PHYSICAL EXAM
======================
VS: T: 97.7 PO BP: 154 / 77 HR: 86 RR: 16 SaO2: 95 RA
GENERAL: Cachectic and chronically ill-appearing woman, sitting
upright in bed
HEENT: Dry mucous membranes. NGT in place draining bilious
fluid, less than days prior. This was removed just prior to
discharge
CV: Regular rate and rhythm, systolic murmur best over left
sternal border
PULM: Breathing comfortably on room air, no accessory muscle
use, clear to auscultation bilaterally
ABD: Soft, non distended, nontender throughout without rebound
or guarding
EXT: Warm, trace edema
SKIN: Has several bruise-appearing lesions over abdomen related
to pemphigus, stable per patient
NEURO: ___ grossly in tact, able to move all 4 extremities
spontaneously
ACCESS: Right chest port, dressing c/d/i
Pertinent Results:
CYTOLOGY FROM PARACENTESIS ___:
Peritoneal fluid:
POSITIVE FOR MALIGNANT CELLS.
Consistent with adenocarcinoma of gynecologic origin. A serous
ovarian carcinoma is favored.
Note: Immunohistochemistry performed shows the following profile
in the tumor cells:
Positive: ___, B72.3, PAX8, CK7, WT1
Negative: CK20, TTF-1, CDX-2, calretinin
ADMISSION LABS
==============
___ 11:30AM BLOOD WBC-9.2 RBC-3.44* Hgb-11.1* Hct-36.1
MCV-105* MCH-32.3* MCHC-30.7* RDW-12.5 RDWSD-47.8* Plt ___
___ 11:30AM BLOOD Neuts-87.7* Lymphs-5.0* Monos-6.5
Eos-0.2* Baso-0.2 Im ___ AbsNeut-8.06* AbsLymp-0.46*
AbsMono-0.60 AbsEos-0.02* AbsBaso-0.02
___ 11:30AM BLOOD Glucose-144* UreaN-28* Creat-1.2* Na-142
K-3.4* Cl-100 HCO3-29 AnGap-13
___ 11:30AM BLOOD ALT-10 AST-21 AlkPhos-55 TotBili-0.5
___ 11:30AM BLOOD Lipase-28
___ 11:30AM BLOOD Albumin-3.8 Calcium-9.1 Phos-3.7 Mg-1.8
___ 11:45AM BLOOD Lactate-1.3
MICROBIOLOGY
============
___ 11:30 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 4:20 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 12:25 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
___ 12:25PM URINE Color-Yellow Appear-Clear Sp ___
___ 12:25PM URINE Blood-NEG Nitrite-NEG Protein-100*
Glucose-NEG Ketone-10* Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 12:25PM URINE RBC-2 WBC-3 Bacteri-NONE Yeast-NONE Epi-1
TransE-<1
___ 12:25PM URINE CastHy-10*
___ 12:25PM URINE Mucous-MANY*
IMAGING
=======
CT ABDOMEN AND PELVIS W CONTRAST, ___:
1. Short segment of small bowel wall thickening and wall edema
in the mid
abdomen with few fluid filled loops of small bowel, most
compatible with
enteritis.
2. Redemonstration of large volume ascites.
3. New ground-glass opacities in the right lower lobe.
Correlate clinically for aspiration or pneumonia.
4. Stable dilation of the main pancreatic duct and CBD without
obstructing
lesion.
KUB, ___:
1. Mildly dilated loops of small bowel with air-fluid levels in
the absence of colonic dilatation suggest partial small bowel
obstruction. CT may be performed if further characterization
is needed.
2. Ascites as well as small bilateral pleural effusions.
___ GUIDED PARACENTESIS, ___:
1. Technically successful ultrasound guided therapeutic
paracentesis.
2. 1.75 L of fluid were removed.
KUB, ___:
Unchanged appearance of dilated loops of fossa bowel with
air-fluid levels
remain concerning for small bowel obstruction.
KUB, ___:
Unchanged appearance of dilated loops of small bowel with
air-fluid levels
consistent with a partial small-bowel obstruction when compared
to prior
radiograph dated ___.
OTHER PERTINENT STUDIES
=======================
___ 12:50PM BLOOD CA125-74*
___ 05:24AM BLOOD TSH-0.89
___ 05:24AM BLOOD Ret Aut-2.6* Abs Ret-0.08
___ 05:24AM BLOOD VitB12-1656* Ferritn-286*
___ 05:03AM BLOOD freeCa-1.09*
___ 03:49AM BLOOD Triglyc-203*
DISCHARGE LABS
==============
___ 05:25AM BLOOD WBC-6.7 RBC-3.22* Hgb-10.3* Hct-33.4*
MCV-104* MCH-32.0 MCHC-30.8* RDW-12.2 RDWSD-46.4* Plt ___
___ 05:25AM BLOOD Glucose-143* UreaN-8 Creat-0.8 Na-137
K-3.9 Cl-99 HCO3-27 AnGap-11
___ 05:25AM BLOOD Calcium-7.7* Phos-2.8 Mg-2.3
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ondansetron 8 mg PO Q8H:PRN Nausea/Vomiting - First Line
2. PredniSONE 5 mg PO DAILY
3. Prochlorperazine 10 mg PO Q8H:PRN Nausea/Vomiting - Second
Line
4. Metoprolol Succinate XL 50 mg PO DAILY
5. Docusate Sodium 100 mg PO BID
6. Polyethylene Glycol 17 g PO DAILY
7. betamethasone, augmented 0.05 % topical BID
8. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP BID
9. Simvastatin 20 mg PO QPM
10. Mycophenolate Mofetil 1000 mg PO QAM
11. Mycophenolate Mofetil 500 mg PO QHS
12. Multivitamins 1 TAB PO DAILY
13. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit oral BID
14. Cyanocobalamin 1000 mcg PO DAILY
Discharge Medications:
1. Bisacodyl ___ID:PRN Constipation - Second Line
2. Dexamethasone 4 mg PO DAILY
3. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN Pain - Severe
Reason for PRN duplicate override: Alternating agents for
similar severity
4. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
5. LORazepam 0.25 mg PO Q4H:PRN nausea
6. OxyCODONE SR (OxyCONTIN) 10 mg PO Q12H
7. Mycophenolate Mofetil 1000 mg PO QAM
8. Mycophenolate Mofetil 500 mg PO QHS
9. Ondansetron 8 mg PO Q8H:PRN Nausea/Vomiting - First Line
10. Prochlorperazine 10 mg PO Q8H:PRN Nausea/Vomiting - Second
Line
11. HELD- betamethasone, augmented 0.05 % topical BID Duration:
2 Weeks This medication was held. Do not restart betamethasone,
augmented until your doctor tells you to do so
12. HELD- Polyethylene Glycol 17 g PO DAILY This medication was
held. Do not restart Polyethylene Glycol until your doctor tells
you it is safe to do so
13. HELD- Triamcinolone Acetonide 0.1% Ointment 1 Appl TP BID
This medication was held. Do not restart Triamcinolone Acetonide
0.1% Ointment until your doctor tells you to do so
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
Malignant bowel obstruction
Metastatic high grade serous adenocarcinoma, likely ovarian
Malnutrition
SECONDARY:
IgA/IgG pemphigus foliaceus
Macrocytic anemia
Hypertension
Hyperglycemia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: History: ___ with fall, +headstrike// fracture, dislocation,
bleed
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal reformations as well as bone algorithm
reconstructions were provided and reviewed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 16.0 s, 16.3 cm; CTDIvol = 49.3 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: CT head ___
FINDINGS:
There is no evidence of infarction, hemorrhage, edema, or mass. There is
prominence of the ventricles and sulci suggestive of involutional changes.
Atherosclerosis seen in intracranial ICAs and bilateral distal vertebral
arteries.
There is no evidence of fracture. There is partial opacification of the
anterior right ethmoidal air cells, mucosal thickening in posterior mucosal
ethmoidal air cells. The remainder visualized portion of the paranasal
sinuses, mastoid air cells, and middle ear cavities are clear. The visualized
portion of the orbits are unremarkable.
IMPRESSION:
1. No evidence fracture, mass, hemorrhage or infarction.
2. Paranasal sinus disease.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST Q311 CT SPINE
INDICATION: History: ___ with fall, +headstrike// fracture, dislocation,
bleed fracture, dislocation, bleed
TECHNIQUE: Non-contrast helical multidetector CT was performed. Soft tissue
and bone algorithm images were generated. Coronal and sagittal reformations
were then constructed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 5.6 s, 22.0 cm; CTDIvol = 23.0 mGy (Body) DLP = 505.6
mGy-cm.
Total DLP (Body) = 506 mGy-cm.
COMPARISON: CT cervical spine ___
FINDINGS:
Alignment is normal. No fractures are identified. Unchanged mild-to-moderate
multilevel degenerative changes with osteophyte formation, most prominent at
C5-C6 and C6-C7 and T1-T2 levels. Mild-to-moderate neural foraminal stenosis
remains worse at C5-C6 and C6-C7 due to uncovertebral spurring. There is no
evidence of spinal canal stenosis.There is no prevertebral soft tissue
swelling.
IMPRESSION:
1. No evidence of fracture or subluxation.
2. Stable multilevel degenerative changes worse at C5-C6 and C6-C7 levels.
Radiology Report
EXAMINATION: CT ABD AND PELVIS WITH CONTRAST
INDICATION: NO_PO contrast; History: ___ with abdominal pain, vomitingNO_PO
contrast// mass, infection
TECHNIQUE: Single phase contrast: MDCT axial images were acquired through the
abdomen and pelvis following intravenous contrast administration.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Stationary Acquisition 3.5 s, 0.5 cm; CTDIvol = 16.9 mGy (Body) DLP =
8.4 mGy-cm.
2) Spiral Acquisition 6.6 s, 51.6 cm; CTDIvol = 8.0 mGy (Body) DLP = 413.3
mGy-cm.
Total DLP (Body) = 422 mGy-cm.
COMPARISON: CT abdomen pelvis and chest ___.
FINDINGS:
LOWER CHEST: New ground-glass opacities in the right lower quadrant are
incompletely evaluated. Incompletely seen also is a atelectasis in the right
middle lobe. Coronary calcifications. No pleural effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout with
few hypodensities again seen, too small to characterize, but likely hepatic
cysts. There is no evidence of focal lesions. There is no evidence of
intrahepatic biliary dilatation. The CBD continues to be prominent to the
level of the ampulla. The gallbladder contains gallstones without wall
thickening or surrounding inflammation. Fundal adenomyomatosis.
PANCREAS: The pancreas has normal attenuation throughout. Dilation of the
main pancreatic duct is unchanged from prior, without evidence of obstructing
lesion. There is no peripancreatic stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
Tiny hypodensities bilaterally are too small to characterize. There is no
evidence of focal renal lesions or hydronephrosis. There is no perinephric
abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Short-segment of small bowel
in the mid abdomen shows edematous and thickened wall. Multiple loops of
small bowel seen the right and mid abdomen are fluid-filled, with air-fluid
levels small bowel in the right and lower abdomen, present air-fluid levels,
edematous and thickened wall. The with target sign seen in the mid abdomen
(2:63). There is normal enhancement throughout. The colon and rectum are
within normal limits. Redemonstrated large amount of ascites.
PELVIS: The urinary bladder and distal ureters are unremarkable.
REPRODUCTIVE ORGANS: The visualized reproductive organs are unremarkable.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease
is noted.
BONES: Generalized bone demineralization without acute fractures or suspicious
bone lesions.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. Short segment of small bowel wall thickening and wall edema in the mid
abdomen with few fluid filled loops of small bowel, most compatible with
enteritis.
2. Redemonstration of large volume ascites.
3. New ground-glass opacities in the right lower lobe. Correlate clinically
for aspiration or pneumonia.
4. Stable dilation of the main pancreatic duct and CBD without obstructing
lesion.
Radiology Report
INDICATION: ___ year old woman with gyn malignancy, difficulty tolerating PO//
eval for SBO
TECHNIQUE: Supine and upright abdominal radiographs were obtained.
COMPARISON: CT scan dated ___.
FINDINGS:
Multiple mildly dilated loops of small bowel with air-fluid levels seen in the
right upper quadrant. The colon is not abnormally dilated. Air seen in the
rectum.
There is no free intraperitoneal air.
Osseous structures are unremarkable. Central displacement of the bowel loops
in keeping with ascites. Small bilateral pleural effusions
There are no unexplained soft tissue calcifications or radiopaque foreign
bodies.
IMPRESSION:
1. Mildly dilated loops of small bowel with air-fluid levels in the absence
of colonic dilatation suggest partial small bowel obstruction. CT may be
performed if further characterization is needed.
2. Ascites as well as small bilateral pleural effusions.
Radiology Report
EXAMINATION: ULTRASOUND-GUIDED THERAPEUTIC PARACENTESIS
INDICATION: ___ year old woman with metastatic GYN cancer and large volume
ascites on CT abdomen. Request for ultrasound-guided therapeutic
paracentesis.
TECHNIQUE: Limited grayscale ultrasound imaging of the abdomen demonstrated
moderate ascites. A suitable target in the deepest pocket in the left lower
quadrant was selected for paracentesis.
COMPARISON: Comparison to prior therapeutic paracentesis from ___.
Comparison to prior CT abdomen/pelvis from ___.
FINDINGS:
Limited grayscale ultrasound imaging of the abdomen demonstrated moderate
ascites. A suitable target in the deepest pocket in the left lower quadrant
was selected for paracentesis.
PROCEDURE: Ultrasound guided therapeutic paracentesis
Location: left lower quadrant
Fluid: 1.75 L of serosanguinous fluid
Samples: None
The procedure, risks, benefits and alternatives were discussed with the
patient and written informed consent was obtained.
A preprocedure time-out was performed discussing the planned procedure,
confirming the patient's identity with 3 identifiers, and reviewing a
checklist per ___ protocol.
Under ultrasound guidance, an entrance site was selected and the skin was
prepped and draped in the usual sterile fashion. 1% lidocaine was instilled
for local anesthesia.
Ascites fluid was aspirated via a 5 ___ catheter advanced into the largest
fluid pocket.
The patient tolerated the procedure well without immediate complication.
Estimated blood loss was minimal.
Dr. ___ supervised the trainee during the key components
of the procedure and reviewed and agrees with the trainee's findings.
IMPRESSION:
1. Technically successful ultrasound guided therapeutic paracentesis.
2. 1.75 L of fluid were removed.
Radiology Report
INDICATION: ___ year old woman with metastatic serous carcinoma of GYN origin
with likely pSBO// SBO?
TECHNIQUE: Supine and upright abdominal radiographs were obtained.
COMPARISON: Prior radiograph dated ___.
FINDINGS:
Small bilateral pleural effusions.
Multiple dilated loops of small bowel with air-fluid levels in the central
abdomen similar in size and appearance to prior radiograph dated ___.
Air is again seen in the descending colon and rectum which are not dilated.
There is no free intraperitoneal air.
Osseous structures are unremarkable.
There are no unexplained soft tissue calcifications or radiopaque foreign
bodies.
IMPRESSION:
1. Dilated loops of small bowel with air-fluid levels re-demonstrated from
prior radiograph, similar in size and appearance. Consistent with persistent
partial small bowel obstruction. CT may be performed if further
characterization is needed.
2. There is again seen ascites and small bilateral pleural effusions.
Radiology Report
INDICATION: ___ year old woman with metastatic serous carcinoma with pSBO//
?SBO
TECHNIQUE: Supine and upright abdominal radiographs were obtained.
COMPARISON: Prior abdominal radiographs, most recently ___.
FINDINGS:
Again seen are multiple dilated loops of small bowel showing air-fluid levels
similar in dimension as compared to prior radiograph from ___. Air
is no longer seen in colon loops.
Unchanged appearance of intra-abdominal ascites and small bilateral pleural
effusions.
There is no free intraperitoneal air.
Osseous structures are unremarkable.
There are no unexplained soft tissue calcifications or radiopaque foreign
bodies.
IMPRESSION:
Unchanged appearance of dilated loops of fossa bowel with air-fluid levels
remain concerning for small bowel obstruction.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman s/p NGT placement// NGT placement
TECHNIQUE: AP portable chest radiograph
COMPARISON: ___
FINDINGS:
The enteric tube projects over the stomach. A right chest wall Port-A-Cath
tip extends to the cavoatrial junction.
There is blunting of the costophrenic angles bilaterally possibly reflective
of small pleural effusions. There is no pneumothorax identified. The size of
the cardiac silhouette is within normal limits.
IMPRESSION:
The enteric tube projects over the stomach.
Small bilateral pleural effusions.
Radiology Report
INDICATION: ___ year old woman with Metastatic serous carcinoma with pSBO//
Still obstructed?
TECHNIQUE: Supine and upright abdominal radiographs were obtained.
COMPARISON: Prior abdominal radiographs, most recently ___ and ___.
FINDINGS:
Multiple dilated loops of small bowel are again demonstrated showing air-fluid
levels similar in dimension when compared to prior. There is no air
visualized within the large bowel.
There is no free intraperitoneal air.
Osseous structures are notable for calcific changes in the costochondral
cartilage.
There are no unexplained soft tissue calcifications or radiopaque foreign
bodies. There has been interval placement of a gastric tube with the side port
and tip within the gastric body.
There are small bilateral pleural effusions. A prepectoral port is seen
overlying the right anterior chest wall.
IMPRESSION:
Unchanged appearance of dilated loops of small bowel with air-fluid levels
consistent with a partial small-bowel obstruction when compared to prior
radiograph dated ___.
Gender: F
Race: ASIAN - CHINESE
Arrive by WALK IN
Chief complaint: Constipation, s/p Fall
Diagnosed with Unspecified abdominal pain
temperature: 98.4
heartrate: 87.0
resprate: 18.0
o2sat: 100.0
sbp: 108.0
dbp: 60.0
level of pain: 7
level of acuity: 3.0 | SUMMARY:
___ year old woman with metastatic serous carcinoma and malignant
ascites s/p 6 cycles of second line therapy with
paclitaxel/carboplatin (___) who presented with
nausea/vomiting and constipation, found to have a malignant
partial bowel obstruction, with course complicated by high
symptom burden and malnutrition.
On ___, the patient and her family requested that she be
discharged with the plan to go to the ___ emergency department
in order to seek a second opinion. While we support patient
autonomy, this decision occurred against medical advice. The
family understands the risks associated with leaving the
hospital at this time though this continues to be their
preference. We have prepared as much of the discharge paperwork
as able in an effort to best facilitate the remainder of her
care. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Hypoxic respiratory failure
Major Surgical or Invasive Procedure:
Cardiac catheterization, stent placement
Intubation w/ mechanical ventilation
History of Present Illness:
Patient is a ___ year old smoker with a past medical history CAD
(h/o multiple stents > ___ yrs ago in ___ and ___ years ago in
___, DM and HTN who present with an acute episode of hypoxic
respiratory failure yesterday in the setting of hypertension and
tachycardia. Patient had at least two ER visits in the past few
days for epigastric pain thought to be due to constipation on
the first visit and to a hiatal hernia on the second visit. Per
daughter, epigastric pain is similar to prior presentations of
ACS requiring PCI and stenting; patient felt strongly that
source of pain was cardiac.
His OSH CXR from his ___ ER visit was unremarkable. After his
second discharge home he continued to have severe epigastric
pain and developed new and rapidly worsening shortness of
breath. EMS was called, and on arrival to the OSH ER (___) he
was hypertensive to 215/113, tachypneic to 27, tachycardic with
a heart rate of 117. Rhythmm unclear sinus vs. SVT, given
adenosine, did not convert. Labs at OSH were significant for wbc
19, creat 1.4, lactate 4, trop 0.27; kub showed no air fluid
levels. Pt saturating 79% on RA and in the 90's on bag mask
ventilation w/ crackles throughout. His respiratory status
quickly decompensated, and he was intubated. Repeat CXR showed a
new RLL infiltrate in a background of mild pulmonary edema.
(clear OSH CXR from two days prior). He was given rocephin,
levofloxacin and lasix 80mg (Uop s/p lasix administration
unknown) and he was transferred to ___.
In the ED, initial vitals were HR 92 BP 120/59 RR 21 satting 99%
(intubated on CMV assist control, FiO2% 70; PEEP:5).
Past Medical History:
1. CARDIAC RISK FACTORS: Diabetes (+), Dyslipidemia (+),
Hypertension (+)
2. CARDIAC HISTORY:
-PERCUTANEOUS CORONARY INTERVENTIONS: At ___ ___ years
ago, at ___, multiple stents placed, unknown anatomy
-PACING/ICD:
3. OTHER PAST MEDICAL HISTORY:
GERD
Social History:
___
Family History:
Noncontributory
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS: HR 62, BP 97/56, RR 20, satting 100% (intubated)
GENERAL: WDWN male in NAD, intubated, sedated.
HEENT: NCAT.
NECK: Supple with JVP of 14 cm.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB anteriorly, no
crackles, wheezes or rhonchi. Poor exam ___ sedation,
intubation.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ DP 2+
Left: Carotid 2+ DP 2+
DISCHARGE PHYSICAL EXAMINATION
Pertinent Results:
ADMISSION LABS
___ 02:36AM BLOOD WBC-11.8* RBC-4.88 Hgb-14.5 Hct-45.1
MCV-93 MCH-29.8 MCHC-32.2 RDW-12.7 Plt ___
___ 04:00AM BLOOD ___ PTT-36.1 ___
___ 02:36AM BLOOD Glucose-252* UreaN-29* Creat-1.5* Na-143
K-5.5* Cl-106 HCO3-22 AnGap-21*
___ 02:36AM BLOOD ALT-30 AST-43* CK(CPK)-286 AlkPhos-73
TotBili-0.8
___ 02:36AM BLOOD Albumin-3.9 Calcium-8.3* Phos-3.2 Mg-1.9
___ 03:55AM BLOOD Type-ART Temp-37.1 PEEP-5 FiO2-70
pO2-125* pCO2-46* pH-7.38 calTCO2-28 Base XS-1 -ASSIST/CON
Intubat-INTUBATED
OTHER PERTINENT LABS
___ 02:36AM BLOOD CK-MB-34* MB Indx-11.9* proBNP-1196*
___ 02:36AM BLOOD cTropnT-0.30*
___ 08:57AM BLOOD CK-MB-79* MB Indx-14.9* cTropnT-1.19*
___ 08:04PM BLOOD CK-MB-62* cTropnT-2.78*
___ 06:31AM BLOOD CK-MB-65* MB Indx-4.9 cTropnT-2.05*
___ 02:49AM BLOOD Lactate-2.9*
___ 03:49PM BLOOD Lactate-1.1
___ 08:39PM BLOOD Lactate-1.0
ECHO ___
The left atrium is moderately dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity is
moderately dilated. There is an apical left ventricular
aneurysm. There is also a posterobasal left ventricular
aneurysm. Overall left ventricular systolic function is severely
depressed (LVEF = 15 %) secondary to extensive anterior, septal,
apical, and posterobasal akinesis with focal apical dyskinesis.
The rest of the left ventricle is hypokinetic. No masses or
thrombi are seen in the left ventricle. The remaining left
ventricular segments are hypokinetic. Right ventricular chamber
size and free wall motion are normal. The aortic root is mildly
dilated at the sinus level. The aortic valve is not well seen.
There is no aortic valve stenosis. No aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. There is
no mitral valve prolapse. Trivial mitral regurgitation is seen.
There is a trivial/physiologic pericardial effusion.
IMPRESSION: profound left ventricular systolic dysfunction, most
likely of coronary etiology, with preserved right ventricular
contractile function
CXR ___
FINDINGS: In comparison with study of ___, there has been some
decrease in the consolidation at the right base. Continued mild
enlargement of the
cardiac silhouette with evidence of pulmonary edema. The tip of
the
endotracheal tube measures approximately 4.5 cm above the
carina. ___-Ganz catheter from the femoral region extends to
the right pulmonary artery.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Donnatol 0.4 mg PO DAILY
2. Ramipril 20 mg PO DAILY
Hold for SBP<100
3. Clopidogrel 75 mg PO DAILY
4. Metoprolol Tartrate 50 mg PO BID
5. glimepiride *NF* 2 mg Oral qd
6. Furosemide 40 mg PO DAILY
7. Aspirin 81 mg PO DAILY
8. Omeprazole 40 mg PO DAILY
9. lansoprazole *NF* 15 mg Oral daily
10. Nitroglycerin SL 0.4 mg SL PRN chest pain
Discharge Medications:
1. Outpatient Lab Work
check chem-7 and INR on ___ with results to Dr.
___ at Phone: ___
Fax: ___
ICD 9 428
2. Nitroglycerin SL 0.4 mg SL PRN chest pain
RX *nitroglycerin 0.4 mg one tab sublingually every 5 minutes
for a total of 3 doses Disp #*25 Tablet Refills:*0
3. Aspirin 81 mg PO DAILY
4. Furosemide 40 mg PO DAILY
5. Omeprazole 40 mg PO DAILY
6. Atorvastatin 80 mg PO DAILY
RX *atorvastatin 80 mg one tablet(s) by mouth daily Disp #*30
Tablet Refills:*2
7. Benzonatate 100 mg PO TID
RX *benzonatate 100 mg one capsule(s) by mouth three times a day
Disp #*30 Capsule Refills:*0
8. Eplerenone 12.5 mg PO DAILY
RX *eplerenone 25 mg 0.5 (One half) tablet(s) by mouth daily
Disp #*15 Tablet Refills:*2
9. glimepiride *NF* 2 mg ORAL QD
10. Lansoprazole *NF* 15 mg ORAL DAILY
11. Donnatol 0.4 mg PO DAILY
12. Levofloxacin 500 mg PO DAILY Duration: 3 Days
RX *levofloxacin 500 mg one tablet(s) by mouth daily Disp #*3
Tablet Refills:*0
13. Lisinopril 10 mg PO DAILY
RX *lisinopril 20 mg one tablet(s) by mouth daily Disp #*30
Tablet Refills:*2
14. Metoprolol Succinate XL 100 mg PO DAILY
RX *metoprolol succinate 100 mg one tablet(s) by mouth daily
Disp #*30 Tablet Refills:*2
15. TiCAGRELOR 90 mg PO BID
do not stop taking this medicine or skip any doses unless Dr.
___ that it is OK to do so.
RX *ticagrelor [Brilinta] 90 mg one tablet(s) by mouth twice a
day Disp #*60 Tablet Refills:*2
16. Warfarin 5 mg PO DAILY16
check your warfarin level on ___.
RX *warfarin 5 mg one tablet(s) by mouth dailiy Disp #*30 Tablet
Refills:*2
17. Levofloxacin 500 mg PO DAILY Duration: 3 Days
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Non ST elevation Myocardial Infarction
Acute systolic heart failure
Acute on chronic kidney injury
atrial tachycardia
Diabetes mellitus
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Intubated for dyspnea at outside ___, here to evaluate for
pulmonary edema and ETT position.
COMPARISON: Outside chest radiographs performed at ___ dated
___ and ___.
TECHNIQUE: Portable supine frontal radiograph of the chest.
FINDINGS:
An endotracheal tube is in place with the tip terminating just at the level of
the thoracic inlet 9 cm above the carina. An orogastric tube is seen coursing
below the diaphragm and out of view on this image. There is a focal airspace
consolidation in the right lung base on this single frontal view, which is
unchanged from ___ at which time the patient was also intubated but
new from the pre intubation study of ___. Mild pulmonary vascular
congestion and edema is improved from ___. No significant pleural
effusion or pneumothorax is detected. The cardiac silhouette is enlarged but
stable. The mediastinal contours are within normal limits. The trachea is
midline.
IMPRESSION:
1. Right basilar consolidation new from pre intubation chest radiograph of ___ raises the possibility of aspiration. Less likely, this may
represent asymmetric flash pulmonary edema.
2. Mild pulmonary vascular congestion and edema improved from ___.
2. ET tube at thoracic inlet. NG tube below the diaphragm.
Radiology Report
HISTORY: Pulmonary edema.
FINDINGS: In comparison with study of ___, there has been some decrease in
the consolidation at the right base. Continued mild enlargement of the
cardiac silhouette with evidence of pulmonary edema. The tip of the
endotracheal tube measures approximately 4.5 cm above the carina. Swan-Ganz
catheter from the femoral region extends to the right pulmonary artery.
Gender: M
Race: WHITE - OTHER EUROPEAN
Arrive by AMBULANCE
Chief complaint: INTUBATED
Diagnosed with ACUTE LUNG EDEMA NOS
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: nan | ___ year old smoker with PMH significant for CAD s/p multiple
stents over a decade prior who presented w/ several days of
epigastric pain w/ negative cardiac and GI workup in OSH ED, and
who then developed chest pain and dyspnea concerning for cardiac
event.
# NSTEMI. Pt transferred from outside hospital with hypertension
to 200 and flash pulmonary edema, thought like secondary to
hypertensive urgency vs ACS. EKG showed nonspecific ST changes,
difficult to interpret, initial troponin 0.30. Patient diuresed,
TTE showed severely depressed LVEF (15%) and profound L
ventricular systolic dysfunction. Second trop 1.19, and pt sent
to cath lab. Cardiac catheterization revealed 90% stenosis of
ostial LAD, 95% stenosis of RCA (see reports for details), ___
___ to both. Pt started on ticagrelor as he had been on
plavix with significant restenosis of his prior stents. He was
diuresed with significant improvement in pulmonary function, and
weaned from the vent the day after his catheterization. He was
started on atorvastatin 80 mg, and his home beta blocker and
ACEi were restarted. Owing to akinesis of the cardiac apex by
echo and concern for thrombosis, warfarin was started with
heparin bridge. At 1 am on morning of ___ pt entered atrial
tachycardia to 140, unclear sinus tach vs. ectopic rhythm, BP
stable. Pt c/o mild CP, received nitro x 2, resolved. EKG showed
no STE or depressions, no significant change from prior; pt
spontaneously converted back to sinus at about 2 am, remained in
sinus. Pt was cleared by ___, received education regarding sodium
intake and weight monitoring, and was sent home on ___ to
follow up with his outpatient cardiologist for further
management.
#PNA. Patient had a R middle lobe consolidation on admission
concerning for a community acquired vs. aspiration pneumonia (if
the latter, possibly precipitated by intubation). Pt was
initially treated with vanc/zosyn for broad coverage, but given
pt's rapid clinical improvement antibiotics were narrowed to
levofloxacin. He was sent home with a prescription for levo to
finish out a ___. Pt admitted with creatinine of 1.5, unclear baseline. If
acute, likely ___ poor forward flow in setting of hypertensive
urgency. Cr was 1.4 on discharge, will f/u as an outpatient to
ensure return to baseline.
#DM. Pt's home PO meds were held while in house, with glucose
well controlled. He was restarted on home meds at discharge.
# Epigastric pain. Possibly anginal equivalent, also quite
possibly unrelated. GI labs unremarkable except mildly elevated
AST. Nornal lipase, normal bili. KUB at OSH unremarkable. Pt
sent home on increased dose of omeprazole, and will follow up
with his PCP for further management.
TRANSITIONAL ISSUES
-Pt will need a follow up echo in 6 weeks to reevaluate his wall
motion abnormalities. He may also be a candidate for ICD
placement if his EF does not improve.
-Pt will f/u with his PCP to ensure return to baseline renal
fxn, to manage his anticoagulation, to evaluate his abdominal
pain with possible referral to a gastroenterologist, and to
follow his other chronic medial issues. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Cephalosporins / Aztreonam
Attending: ___.
Chief Complaint:
altered mental status
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Patient is a ___ year old woman with diabetes mellitus type 2
(last A1C 5.3%) complicated by gastroparesis/neuropathy/foot
ulcer in RLE/nephropathy, CKD stage V not on HD, HTN, HLD, PVD,
asthma, obesity who presents with altered mental status in the
setting of hypoglycemia.
Per chart review, patient has a complicated history of type 2 DM
diagnosed at an early age. She was previously on insulin therapy
however given frequent admissions for hypoglycemia in the
setting of progressive kidney dysfunction, her ___ provider
has stopped ___ and currently she is on glipizide 2.5mg BID
which patient reports she has been adherent with. She recently
underwent endometrial ablation and cervical lac repair under
anesthesia (800cc EBL ___ with improvement in control of
menstrual cycles. Yesterday, she reports feeling well and went
to bed last night after taking her ___ meds. She reports she does
not remember what happened today. Per report from family, pt was
found to be altered in the monrning and hypoglycemic with a BG
of 28. EMS called, she was given glucagon. On arrival pt
disoriented to self, but knows she is at the hospital, unable to
provide much history due to altered mental status.
In the ED, initial VS were: 96.9 100 171/95 14 100% RA . On
arrival ___ 100
ED physical exam was recorded as: oriented x 0 --> repeat exam-
oriented x3- still very poor historian. unable to perform ED
pelvic exam due to pain. ROS + non specific abdominal pain
ED labs were notable for:
WBC 12
H/H 9.5/27.4
plt 405
BUN/Cr ___
gap 24
HCO 14
K 8.6 --> 4.6
Ca 8, Phos 6.5
alk phos 128
lactate 1.1
serum tox negative
Imaging showed: CXR with no intrathroacic process
Patient refused other imaging studies
Ob gyn was consulted due to initial concern for endometritis
given mild leukocytosis and recent procedure. Given that pt
reports baseline pain with pelvic exam to the point of requiring
sedation for the exams, bimanual exam may not aid in diagnosis
therefore not attempted. Recommended continued monitoring for
signs/symptoms of infection and consideration of presumptive
treatment for endometritis if clinical concern increases.
Being admitted for management of blood sugars and for dialysis
consult.
Patient was given:
___ 08:00 IVF 1000 mL NS 1000 mL
___ 08:00 PO Acetaminophen 650 mg
___ 09:04 IH Albuterol 0.083% Neb Soln 1 NEB
___ 11:20 IVF 1000 mL D10W
___ 12:29 IVF 1000 mL NS 1000 mL
___ 15:40 IVF 1000 mL D10W
___ 15:40 PO Acetaminophen 650 mg
Transfer VS were: 97.8 101 167/82 18 100% RA
When seen on the floor, she is oriented times 3. She reports
her sugars have been low recently prompting stopping her
insulin. She thinks her kidney function is worse due to
medications that were prescribed to her in the past. She is
convinced that her diabetes is contributing to her CKD. She is
refusing dialysis. She denies headache, cough, chest pain,
shortness of breath, abdominal or pelvic pain.
REVIEW OF SYSTEMS:
A ten point ROS was conducted and was negative except as above
in the HPI.
Past Medical History:
DM c/b gastroparesis/neuropathy/foot ulcer in RLE/nephropathy
HTN
hypercholesterolemia
PVD
asthma
CKD stage V
obesity
chronic cognitive deficits
Social History:
___
Family History:
Diabetes in her mother, and 5 of her 6 siblings. Per patient
report, mother died while on hemodialysis.
Physical Exam:
Gen: NAD, lying in bed
Eyes: EOMI, sclerae anicteric
ENT: MMM, OP clear
Cardiovasc: RRR, no MRG, full pulses, no edema
Resp: normal effort, no accessory muscle use, lungs CTA ___.
GI: soft, NT, ND, BS+
MSK: No significant kyphosis. No palpable synovitis. Right BKA.
RUE AVF with bruit and thrill
Skin: No visible rash. No jaundice.
Neuro: AAOx3. No facial droop.
Psych: Full range of affect
aox3, awake and apppropiate
clear breath sounds
regular pulse
soft abdomen
Pertinent Results:
___ 11:30AM GLUCOSE-53* UREA N-41* CREAT-5.8* SODIUM-137
POTASSIUM-4.7 CHLORIDE-104 TOTAL CO2-14* ANION GAP-24*
___ 08:24AM GLUCOSE-56* UREA N-41* CREAT-5.4* SODIUM-136
POTASSIUM-7.3* CHLORIDE-103 TOTAL CO2-16* ANION GAP-24*
___ 11:40AM K+-4.6
___ 08:24AM ALT(SGPT)-18 AST(SGOT)-40 ALK PHOS-133* TOT
BILI-0.3
___ 08:24AM LIPASE-26
___ 08:24AM ALBUMIN-4.3 CALCIUM-8.3* PHOSPHATE-6.8*
MAGNESIUM-2.1
___ 08:24AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 08:24AM WBC-12.0* RBC-3.38* HGB-9.5* HCT-27.4*
MCV-81* MCH-28.1 MCHC-34.7 RDW-14.5 RDWSD-41.8
___ 08:24AM PLT COUNT-405*
___ 08:24AM ___ PTT-28.8 ___
___ 07:35AM GLUCOSE-73 UREA N-43* CREAT-5.4* SODIUM-136
POTASSIUM-7.1* CHLORIDE-106 TOTAL CO2-12* ANION GAP-24*
___ 07:35AM ALT(SGPT)-17 AST(SGOT)-34 ALK PHOS-128* TOT
BILI-0.3
___ 07:35AM LIPASE-24
___ 07:35AM ALBUMIN-4.1 CALCIUM-8.0* PHOSPHATE-6.5*
MAGNESIUM-2.0
___ 07:35AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 07:27AM LACTATE-1.1 K+-8.6*
___ 04:50PM BLOOD WBC-10.2* RBC-3.04* Hgb-8.5* Hct-24.0*
MCV-79* MCH-28.0 MCHC-35.4 RDW-14.7 RDWSD-41.9 Plt ___
___ 06:45AM BLOOD Glucose-110* UreaN-38* Creat-5.2* Na-138
K-4.7 Cl-107 HCO3-18* AnGap-18
___ 06:25AM BLOOD ALT-13 AST-14 LD(LDH)-240 AlkPhos-118*
___ 08:24AM BLOOD Albumin-4.3 Calcium-8.3* Phos-6.8* Mg-2.1
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 10 mg PO DAILY
2. Clonidine Patch 0.3 mg/24 hr 1 PTCH TD QWED
3. Albuterol Inhaler 1 PUFF IH Q6H:PRN wheezing
4. Gabapentin 300 mg PO TID
5. Fluticasone Propionate 110mcg 1 PUFF IH BID
6. Calcitriol 1 mcg PO 2X/WEEK (___)
7. Calcitriol 0.25 mcg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
hypoglycemia
encephalopathy
diabetes typ2 complicated by
esrd
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: History: ___ with AMS // ?cpd
TECHNIQUE: PA and lateral views of the chest provided.
COMPARISON: Chest radiograph dated ___.
FINDINGS:
Lung volumes are normal. There is no focal consolidation, effusion or
pneumothorax. There is no central vascular congestion or overt pulmonary
edema. Mediastinal and hilar contours are normal. Heart size is normal.
IMPRESSION:
No acute intrathoracic process.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Hypoglycemia
Diagnosed with Type 2 diabetes mellitus with hypoglycemia without coma
temperature: 96.9
heartrate: 88.0
resprate: 12.0
o2sat: 98.0
sbp: 120.0
dbp: 80.0
level of pain: 0
level of acuity: 2.0 | Patient is a ___ year old woman with diabetes mellitus
complicated by gastroparesis/neuropathy/foot ulcer in
RLE/nephropathy, CKD stage V not on HD, HTN, HLD, PVD, asthma,
obesity who presents with altered mental status in the setting
of hypoglycemia.
# AMS
# Hypoglycemia
# DM: type 2 DM with positive C-peptide and A1C 5.7%, now
improved from prior. Her insulin was stopped recently due to
progressive kidney dysfunction. SHe is only on glipizide 2.5mg
BID. Patient measures ___ twice daily and reports AM ___ 70-100s
and ___ usually < 200. Reports she has not had hypoglycemic
episodes in months. Per ___ note in ___, home glucose
monitoring showed no glucose levels below 75 mg/dl with an
average of ~ 164 (A1C ~ 7.5%). Taking liquid gabapentin
occasionally for neuropathy, but only at bedtime because it
makes her sleepy.
Her glucose improved and she was no longer hypoglycemic.
Glipizide was restarted as recommended by her ___ providers.
She was instructed to only take it when she is eating with
meals.
# Vaginal bleeding s/p endometrial ablation
#Acute blood loss anemia during recent endometrial ablation on
top of anemia of CKD
She received two doses of ferraheme recently. During admission
she received one unit of blood for hct 21.4 with improvement to
24 post transfusion and had no signs of active or ongoing
bleeding.
# CKD
- Anemia of chronic disease, hyporproliferative ___ kidney
disease. Some component of iron deficiency, with a saturation of
13% in ___. Gynecology recently given iron infusion in
___. Hb is at baseline
Monitor Hb
- HTN: Hypertensive to 180 on admission. Does not appear to be
volume overloaded and with no O2 requirement. No chest pain,
shortness of breath. Diuretics would
help, but she is not interested in them and likely would not
adhere to electrolyte monitoring. Dialysis would also of course
help, but she is not interested in that.
Continue amlodipine and clonidine
Continue to encourage to consider dialysis
- Acid/base status: bicarb 14, has been on oral bicarb in the
past although currently not taking. I wrote Rx for this but she
declined to take this during admission
- BMD: Ca 8 (at baseline), Ph 6 (higher than recent values).
Likely due to worsening CKD. She is not compliant with calcium
acetate.
On liquid calcitriol however not on formulary here, will start
PO calcitriol 0.25 mcg daily
Starting Ca acetate 667mg TID if patient will accept
# Asthma: On albuterol and fluticasone inhalers
- Continued home regimen
# Chronic issue
Poor health literacy and chronic cognitive difficulties (since
head trauma as a child per report) is likely causing impedance
to her medical care. Consider SW consult
She and her brother received instructions not to take glipizide
if she is fasting or not eating and to take it with meals and
also to avoid NSAID medications. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
Codeine
Attending: ___.
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI: ___ year old fa male who had a fall ___ days ago, at that
time
the images of the head and spine were negative for hemorrhage or
fractures. Since her fall ___ days ago she fell again on three
different occasions, and was referred to the ED by her PCP for
evaluation. She denies headaches, dizziness, nausea, or
vomiting.
Past Medical History:
PMHx:
1. Dementia
2. Hypercholesterolemia
3. Osteoporosis
4. Depression
5. Urinary incontinence
Social History:
___
Family History:
NC
Physical Exam:
PHYSICAL EXAMINATION ON ADMISSION:
O: T: 98.3 BP: 118/48 HR: 68 R: 16 O2Sats: 98%
Gen: WD/WN elderly lady , comfortable, NAD.
Neck: Supple.
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, and hospital (baseline)
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 2 to 1
mm bilaterally.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power ___ throughout. No pronator drift
Sensation: Intact to light touch t/o.
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger.
PHYSICAL EXAMINATION ON DISCHARGE:
A&O to self
PERRL
EOMs intact
MAE with good strength
No pronator drift
Pertinent Results:
CT Cervical Spine: ___
1. No evidence of acute traumatic injury.
2. No significant change from the study 10 days prior with
degenerative
changes as above.
2. Increased sclerosis at the inferior endplate of T1 is stable
since ___ but new since ___ and may represent
compression deformity.
CT Head: ___
1. Acute left subdural hematoma as detailed above. No signs of
herniation.
2. Large left supraorbital hematoma.
Chest X-Ray AP & Lateral: ___
No acute intrathoracic process.
CT Sinus/Mandible/Maxillofacial: ___
1. Mild mucosal thickening of the anterior ethmoidal air cells
and maxillary sinuses bilaterally. Small amount of fluid is
seen layering in the left sphenoid sinus.
2. Stable left supraorbital hematoma, globes are unremarkable.
CT Head: ___
1. Interval increase of a left subdural hematoma with new
extension along the left parietal lobe. Small infratentorial
component is stable. No herniation.
2. Stable left supraorbital hematoma.
Medications on Admission:
Aricept 10 mg daily, Calcium Citrate + 315 mg-200 unit, Namenda
5mg BID, Risperdal 0.5mg BID, Vitamin D3 1,000 unit daily,
Myrbetriq 25 mg daily.
Discharge Medications:
1. Donepezil 10 mg PO HS
2. Heparin 5000 UNIT SC TID
3. RISperidone 0.5 mg PO BID
4. Vitamin D 1000 UNIT PO DAILY
5. Memantine 5 mg PO BID
6. Docusate Sodium 100 mg PO BID
7. Calcium Carbonate 500 mg PO DAILY
8. Bisacodyl 10 mg PO DAILY
9. Acetaminophen 650 mg PO Q4H:PRN pain/fever
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Left Subdural Hematoma
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
CHEST RADIOGRAPH PERFORMED ON ___
COMPARISON: Prior exam from ___.
CLINICAL HISTORY: Worsening falls, question pneumonia.
FINDINGS: AP upright and lateral views of the chest were provided. The lungs
appear clear without focal consolidation, effusion, or pneumothorax. The
cardiomediastinal silhouette is stable and normal. Atherosclerotic
calcifications are seen along the thoracic aorta. Chronic deformity at the
left humeral head is not significantly changed. An old injury of the left
distal clavicle is also stable. No acute bony injuries are seen.
IMPRESSION: No acute intrathoracic process.
Radiology Report
INDICATION: Three falls with head strike within the last week. Evaluate for
bleed.
COMPARISON: CT head, ___.
TECHNIQUE: Axial MDCT images were obtained through the brain without IV
contrast. Multiplanar coronal, sagittal, and thin section bone algorithm
reconstructed images were generated.
FINDINGS: There is an acute left cerebral subdural hemorrhage, layering along
the left tentorium and to a lesser extent extending along the superior falx
(2:11, 10, 17) with a small infratentorial component maximally measuring 8mm
(2:9). No other focus of hemorrhage is detected. There is no evidence of
herniation, edema, mass effect or large territorial infarction. The
ventricles and sulci are prominent, compatible with age-related atrophy.
Periventricular and subcortical white matter hypodensities are nonspecific,
but can be seen in the setting of chronic microvascular ischemic disease. The
basal cisterns are patent and there is preservation of gray-white
differentiation.
No fracture is detected. There is a left supraorbital hematoma (3:6). The
partially visualized paranasal sinuses, mastoid air cells and middle ear
cavities are clear. The globes are grossly intact.
IMPRESSION:
1. Acute left subdural hematoma as detailed above. No signs of herniation.
2. Large left supraorbital hematoma.
Radiology Report
INDICATION: Three falls with head strike within the last week. Evaluate for
bleed.
COMPARISON: Recent CT C-spine ___ and ___
TECHNIQUE: Contiguous helical MDCT images were obtained from the skull base
through the T2 level without IV contrast. Multiplanar axial, coronal,
sagittal and thin section bone algorithm reconstructed images were generated.
TOTAL BODY DLP: 680.05 mGy-cm.
FINDINGS: There is no evidence of acute traumatic fracture or dislocation.
Overall, there is no appreciable change from the study 10 days prior. The
atlantodental interval is preserved. The dens are normally positioned between
the lateral masses of C1. Increased sclerosis at the inferior enplate of T1
(602b:24) is unchanged since ___ but new since ___ and may represent
compression. Overall alignment is preserved. There are moderate degenerative
changes with anterior and posterior osteophytes. Disc osteophyte complexes
cause mild central canal narrowing at C4-C5 and C5-C6. Uncovertebral and
facet joint arthropathy cause mild neural foraminal narrowing at several
vertebral levels.
There is no prevertebral or paravertebral soft tissue abnormality. The
thyroid shows an 8 mm hypodense nodule. The included lung apices are clear.
IMPRESSION:
1. No evidence of acute traumatic injury.
2. No significant change from the study 10 days prior with degenerative
changes as above.
2. Increased sclerosis at the inferior endplate of T1 is stable since ___
but new since ___ and may represent compression deformity.
Updated results called to Dr. ___ by ___ at 5:20 pm, ___.
Radiology Report
HISTORY: Left tentorium hemorrhage. Evaluate for evolution of hemorrhage.
COMPARISON: Prior head CT from ___.
TECHNIQUE: Contiguous axial MDCT images were obtained through the brain
without IV contrast. Sagittal, coronal and bone thin algorithm
reconstructions were generated.
Total exam DLP: 1036 mGy-cm.
CTDI: 63 mGy.
FINDINGS:
There is redemonstration of a in left subdural hemorrhage, layering along the
left tentorium, extending along the superior falx which appears enlarged when
compared to prior examination. There is now also extension along the left
parietal lobe (02:20). Small infratentorial component measures a maximum of 8
mm, not significantly changed since prior examination. No new focus of
hemorrhage is identified. There is no herniation, edema, mass effect or large
territorial infarction. Prominence of cortical sulci, fissures, ventricles
and extra-axial CSF spaces representing atrophy are likely age-related.
Periventricular white matter hypodensities are likely the sequelae of chronic
small vessel ischemic disease. Basal cisterns are patent and there is
preservation of gray-white matter differentiation.
No fracture is detected. Again seen is a left supraorbital hematoma (03:17).
There is mild mucosal thickening of the anterior ethmoidal air cells.
Otherwise, remaining visualized paranasal sinuses, mastoid air cells and
middle ear cavities are clear. The globes are unremarkable.
IMPRESSION:
1. Interval increase of a left subdural hematoma with new extension along the
left parietal lobe. Small infratentorial component is stable. No herniation.
2. Stable left supraorbital hematoma.
Radiology Report
HISTORY: Status post fall with left tentorium hemorrhage. Evaluate for
evolution of hemorrhage.
COMPARISON: Prior head CTs from ___ and ___.
TECHNIQUE: Helical axial images were acquired through the paranasal sinuses.
Coronal and sagittal reformatted images were prepared.
Total exam DLP: 813 mGy-cm.
CTDI: 36 mGy.
FINDINGS:
The frontal sinuses are clear. There is mild mucosal thickening of the
anterior ethmoid air cells. Small amount of fluid is seen layering in the
left sphenoid sinus. Middle ear cavities are clear. There is mild mucosal
thickening of the maxillary sinuses bilaterally. The ostiomeatal units are
patent. The cribriform plates are intact. There is no nasal septal defect.
The lamina papyracea is intact. There is redemonstration of a left
supraorbital hematoma, not significantly changed since prior examination. The
globes are unremarkable. There is no proptosis. Note is made of
calcification of the carotid siphons bilaterally.
IMPRESSION:
1. Mild mucosal thickening of the anterior ethmoidal air cells and maxillary
sinuses bilaterally. Small amount of fluid is seen layering in the left
sphenoid sinus.
2. Stable left supraorbital hematoma, globes are unremarkable.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: S/P FALL
Diagnosed with TRAUMATIC BRAIN HEM NEC, UNSPECIFIED FALL
temperature: 98.3
heartrate: 68.0
resprate: 16.0
o2sat: 98.0
sbp: 118.0
dbp: 48.0
level of pain: 0
level of acuity: 2.0 | Ms. ___ was admitted to the neurosurgery service for
monitoring of the left tentorial hemorrhage s/p fall. On ___,
she underwent a repeat non-contrast head CT which showed a small
increase in the size of the hemorrhage along the tentorium. She
was evaluated by physical therapy who recommended rehab but
needed 3 days inpatient. She remained stable. On ___, she was
placed on SQH and remained stable.
She was discharged on ___ in stable condition. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / aspirin
Attending: ___.
Chief Complaint:
Subdural hematoma
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ Critical is a ___ year old female nursing home resident
on Coumadin for pe who was last seen normal the night prior to
admission. She reportedly woke up with right facial asymmetry
and
incomprehensible speech; she is verbal at baseline. Nursing home
staff was unclear if she had a fall. She was taken to ___ where a ___ was performed and significant for
bilateral subdural hematomas. Her INR at the outside hospital
was
2.5. She was given KCentra and Vitamin K. She was also
hypertensiveat the OSH requiring nicardipine gtt. She was
intubated and transferred to ___ for neurosurgery evaluation.
Past Medical History:
recurrent DVTs on coumadin
type 2 diabetes mellitus
asthma/COPD
coronary artery disease
rheumatoid arthritis
anxiety disorder
muscle wasting and atrophy
major depressive disorder
thoracolumbar disc degeneration
Social History:
___
Family History:
___
Physical Exam:
ON ADMISSION
============
t103 140/99 97 19 94% intubated
Intubated
Neuro: EO to voice, PERRL ___. No commands. Overbreathing vent.
+cough, no gag. Localizing uppers, RUE tremor/asterixis. Mild
contractures bilateral uppers with increased tone. LLE triple
flex to noxious, RLE weak withdrawal.
ON DISCHARGE
============
VITALS: T 98 BP 185/71(syst BP over last 24 h 117-150) HR 80 RR
18
SO2 95 on 1 liters via nasal cannula; weight 118.5 (119.4), 4
soft/loose bowel movements yesterday
___: Appears comfortably lying in her bed.
EYES:PERRLA. EOM intact. No scleral icterus. No conjunctival
redness.
HEENT: Head atraumatic. Poor dentition. Pink and moist mucous
membranes.
CV: Regular rate and rhythm. Normal S1 and S2. Systolic heart
murmur with radiation to both carotid and L axilla. Strong
peripheral pulses.
RESP: Vesicular lung sound bilaterally. No adventitious lungs
sounds on auscultation from anterior.
GI: Bowel sounds present. Abdomen soft, no tenderness, no
rebound, no guarding.
Extremities: No peripheral edema.
SKIN: No rash.
NEURO: A/o x3. Cranial nerve, motor and sensory exam grossly
intact.
Pertinent Results:
Admission Labs:
===============
___ 02:52PM BLOOD WBC-12.9* RBC-4.13 Hgb-11.4 Hct-36.4
MCV-88 MCH-27.6 MCHC-31.3* RDW-13.7 RDWSD-43.8 Plt ___
___ 02:52PM BLOOD Neuts-80.2* Lymphs-14.4* Monos-4.2*
Eos-0.1* Baso-0.4 Im ___ AbsNeut-10.32* AbsLymp-1.85
AbsMono-0.54 AbsEos-0.01* AbsBaso-0.05
___ 02:52PM BLOOD ___ PTT-29.0 ___
___ 02:52PM BLOOD Glucose-333* UreaN-23* Creat-1.2* Na-131*
K-5.0 Cl-92* HCO3-20* AnGap-19*
___ 02:52PM BLOOD ALT-7 AST-18 AlkPhos-109* TotBili-1.4
___ 02:52PM BLOOD Albumin-3.1* Calcium-9.1 Phos-2.9 Mg-1.5*
___ 02:55PM BLOOD Lactate-2.1*
Discharge Labs:
===============
___ 06:30AM BLOOD WBC-7.0 RBC-2.84* Hgb-8.0* Hct-26.5*
MCV-93 MCH-28.2 MCHC-30.2* RDW-15.2 RDWSD-49.8* Plt ___
___ 06:30AM BLOOD Plt ___
___ 06:30AM BLOOD Glucose-225* UreaN-41* Creat-1.3* Na-143
K-4.8 Cl-103 HCO3-27 AnGap-13
___ 06:30AM BLOOD Calcium-9.2 Phos-3.9 Mg-1.7
Microbiology:
=============
___ Urine Culture:
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- R
CEFTAZIDIME----------- 4 S
CEFTRIAXONE----------- =>64 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
___ Urine Culture:
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- R
CEFTAZIDIME----------- 4 S
CEFTRIAXONE----------- =>64 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
___ C. difficile DNA amplification assay:
Positive for toxigenic C difficile by the Cepheid nucleic
amplification assay.
Imaging
=======
___ CT head w/o contrast:
Overall stable, from 9 hours prior, bilateral subdural hematomas
without
midline shift.
___ CT head w/o contrast:
1. Allowing for differences in scanning technique, there is no
significant
interval change from CT head performed ___ at 22:14.
2. Re-demonstration of bilateral convexity, parafalcine, and
tentorial
subdural hematomas, that are essentially unchanged in size.
There is no
significant shift of midline structures.
3. No new evidence of intracranial hemorrhage, or infarct.
___ CT head w/o contrast:
1. Decreased bilateral mixed density subdural hematomas compared
to ___ with near complete resolution of sulcal
effacement, re-expansion of the lateral and third ventricles,
and substantially improved mass effect on the midbrain.
2. No evidence for new intracranial abnormalities.
___ BILAT LOWER EXT VEINS:
No evidence of deep venous thrombosis in the right or left lower
extremity
veins.
___ ABDOMEN ULTRASOUND:
1. Cholelithiasis without signs of obstruction.
2. Echogenic foci in right renal pelvis possibly resulting from
nephrocalcinosis.
3. Right renal cyst.
___ HIP (UNILAT 2 VIEW) W/PELVIS (1 VIEW) RIGHT:
No obvious fracture detected involving the right hip. However,
given the
degree of osteoporosis, if there is high clinical suspicion for
nondisplaced fracture, then MRI or CT could help for further
assessment
Mild right and left hip degenerative changes and degenerative
changes of both SI joints. Dense vascular calcification.
EEG
===
___ EEG:
This is an abnormal continuous ICU EEG monitoring study because
of (1) Amplitude asymmetry with decreased voltages and a
relative attenuation of faster frequencies on the right,
consistent with the known subdural hematoma on that side. (2)
Generalized background slowing consistent with a mild-moderate
encephalopathy, nonspecific with regards to etiology. There are
no electrographic seizures. Compared to the day priors study,
the previously noted left frontotemporal sharp waves are no
longer present, and the background is improved.
Medications on Admission:
aspirin 325mg daily
atorvastatin 20mg daily
Benadryl 25mg bid pRN
budesonide suspension 0.5mg/2ml 1 unit inhale daily for
corticosteroids
cetirizine 10mg daily
Coumadin 6mg/6.5mg QOD
Cymbalta 30mg bid
Colace 100mg bid
florastor 250mg bid
furosemide 20mg 0.5tab qod
isosorbide mononitrate 30mg daily
lactobacillus cap bid
lantus 20units daily at b edtime
metoprolol tartrate 25mg bid
miralax 17g daily
nitrofurantoin macrocrystal 100mg bid for uti x 10 days (started
___
novbolog sliding scale
omeprazole 20mg bid
risperidone 1mg qhs
saline nasal spray
senna 1 tab qhs
vicodin ___ arthritis
vitamin b12 1000mcg daily
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing
3. amLODIPine 10 mg PO DAILY
4. CefTAZidime 1 g IV Q12H UTI Duration: 3 Days
last dose on ___. Heparin 5000 UNIT SC BID
6. Glargine 20 Units Bedtime
Regular 6 Units Breakfast
Regular 6 Units Lunch
Regular 6 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
7. Labetalol 300 mg PO TID
8. Vancomycin Oral Liquid ___ mg PO Q6H
to complete on ___. Aspirin 81 mg PO DAILY
10. DULoxetine 50 mg PO DAILY
11. Atorvastatin 20 mg PO QPM
12. B-12 DOTS (cyanocobalamin (vitamin B-12)) 1000 mcg oral
DAILY
13. Budesonide Nasal Inhaler 0.5mg/2ml 1 unit nasal DAILY
14. Cetirizine 10 mg PO DAILY
15. ClonazePAM 1 mg PO BID anticonvusant
RX *clonazepam 1 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
16. DiphenhydrAMINE 25 mg PO Q12H:PRN allergies
17. Florastor (Saccharomyces boulardii) 250 mg oral BID
18. Isosorbide Mononitrate 30 mg PO DAILY
19. RisperiDONE 1 mg PO QHS
20. Sodium Chloride Nasal 1 SPRY NU Q2 H nasal congestion
21. HELD- Furosemide 10 mg PO EVERY OTHER DAY This medication
was held. Do not restart Furosemide until ___ talk to your
doctor
22. HELD- Furosemide 20 mg PO EVERY OTHER DAY This medication
was held. Do not restart Furosemide until ___ talk to your
doctor
23. HELD- Furosemide 20 mg PO EVERY OTHER DAY This medication
was held. Do not restart Furosemide until ___ talk to your
doctor
24. HELD- Warfarin 6 mg PO EVERY OTHER DAY This medication was
held. Do not restart Warfarin until reassessment by
neurosurgery.
25. HELD- Warfarin 6.5 mg PO EVERY OTHER DAY This medication
was held. Do not restart Warfarin until ___ talk to neurosurgery
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
bilateral subdural hematomas
E. coli UTI
___
C. diff colitis
Secondary Diagnosis:
Diabetes mellitus
Hyperglycemia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
INDICATION: ___ intubated s/p SDH// ETT placement
TECHNIQUE: Single portable view of the chest.
COMPARISON: Chest x-ray from earlier the same day at 13:33.
FINDINGS:
Endotracheal tube tip is 1.8 cm from the carina, slightly retracted since
prior. Enteric tube passes below the field of view. Lung volumes are
slightly low. There is retrocardiac opacity progressed since prior which
could represent worsening atelectasis. Underlying effusion or
infection/aspiration are possible. Streaky right basilar opacity is likely
atelectasis. Cardiac silhouette is difficult to assess given opacity at the
left lung base. No acute osseous abnormalities.
IMPRESSION:
ET tube tip 1.8 cm from the carina. Dense left basilar opacity, potentially
combination of effusion with atelectasis though infection or aspiration would
be possible.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with bilat SDH, intubated// eval ETT, OGT. r/o
pna eval ETT, OGT. r/o pna
IMPRESSION:
Compared to chest radiographs ___.
Tip of the endotracheal tube is no less than 12 mm from the carina, but it is
probably to close and should be withdrawn 2 cm for better function.
Esophageal drainage tube passes into the mid stomach. Stomach is probably
distended with fluid.
Small left pleural effusion and moderate left basal atelectasis have improved.
Right lung is grossly clear. Moderate enlargement of cardiac silhouette is
stable. No pneumothorax.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: History: ___ with history of PE on coumadin bilat SDH from OSH
p/w intubation and sedated// eval for interval change in bleed
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 5.0 s, 20.0 cm; CTDIvol = 46.7 mGy (Head) DLP =
934.2 mGy-cm.
Total DLP (Head) = 934 mGy-cm.
COMPARISON: CT head without contrast from 9 hours prior
FINDINGS:
Re-demonstrated are bilateral convexity mixed density subdural hematomas,
unchanged since the prior examination, measuring up to 12 mm along the right
frontal convexity. Bilateral parafalcine subdural hematomas are also stable
in size, measuring up to 5 mm in the left priors falcine region. There is no
midline shift. No focal mass or infarct is identified.
Bilateral mucous retention cysts are seen in the maxillary sinuses. The
ethmoid air cells are clear. The mastoid air cells and middle ear cavities
are clear. The visualized portion of the orbits are unremarkable.
IMPRESSION:
1. Overall stable, from 9 hours prior, bilateral subdural hematomas without
midline shift.
Radiology Report
EXAMINATION: PORTABLE HEAD CT W/O CONTRAST Q151 CT HEAD
INDICATION: ___ year old woman with ___ f hx PE on Coumadin INR 2.5 at OSH
given Kcentra/vit K. INR 1 NCHCT consistent with bilateral subdural hematomas,
intubated// assess size of bleed, please perform now thank you
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: DLP: ___ MGy-cm .
COMPARISON: Noncontrast CT head ___.
FINDINGS:
Allowing for differences in scanning technique and patient position, there is
re-demonstration of bilateral convexity mixed density subdural hematomas, that
are essentially unchanged from prior exam performed ___. Bilateral
parafalcine subdural hematomas are also stable in size. Small subdural
hematomas along the tentorium are also appreciated, and unchanged from prior
head CT performed ___. There is no significant shift of midline
structures. There is no new evidence of intracranial hemorrhage, or infarct.
There are no fractures identified.
Bilateral maxillary mucous retention cysts are once again identified. The
remaining visualized paranasal sinuses are clear. The mastoid air cells are
clear. There is a soft tissue density in the right external auditory canal,
which likely represents cerumen. The visualized portion of the orbits are
unremarkable.
IMPRESSION:
1. Allowing for differences in scanning technique, there is no significant
interval change from CT head performed ___ at 22:14.
2. Re-demonstration of bilateral convexity, parafalcine, and tentorial
subdural hematomas, that are essentially unchanged in size. There is no
significant shift of midline structures.
3. No new evidence of intracranial hemorrhage, or infarct.
Radiology Report
EXAMINATION: DX CHEST PORTABLE PICC LINE PLACEMENT
INDICATION: ___ year old woman with picc// r dl picc 53cm iv ___ ___
Contact name: ___: ___ r dl picc 53cm iv ___ ___
IMPRESSION:
ET tube tip is at the level of the carina less than 1.5 cm from the carina and
should be pulled back at least 2 cm.
Right PICC line tip crosses the midline in continues toward the left
brachycephalic vein and and left subclavian vein and should be repositioned.
Bibasal areas of atelectasis and left pleural effusion are unchanged.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with R PICC malpositioned// R PICC repo
attempted, retracted 6cm ___ ___
COMPARISON: Chest radiographs from ___ through earlier on ___
FINDINGS:
Semi supine AP portable view of the chest provided.
The right PICC tip ends in the right atrium. The endotracheal tube tip
extends less than 1 cm past the carina into the proximal right mainstem
bronchus. The nasogastric feeding tube tip ends in the stomach. The
cardiomediastinal silhouette is mildly enlarged, but stable. Bilateral lower
lobe atelectasis is again present, unchanged. There is no pleural effusion,
pulmonary edema or pneumothorax.
IMPRESSION:
1. Right PICC tip ends in the right atrium.
2. Endotracheal tube tip extends less than 1 cm past the carina into the
proximal right mainstem bronchus. Recommend withdrawing the tube by at least
3 cm.
3. Bilateral lower lobe atelectasis, unchanged.
4. Mild cardiomegaly, unchanged.
NOTIFICATION: The findings were discussed with ___, M.D. by
___, M.D. on the telephone on ___ at 3:06 pm, 10 minutes
after discovery of the findings.
Radiology Report
INDICATION: ___ year old woman with ___ f hx PE on Coumadin INR 2.5 at OSH
given Kcentra/vit K. INR 1 NCHCT consistent with bilateral subdural hematomas,
intubated// assess placement of ETT
TECHNIQUE: AP portable chest radiograph
COMPARISON: ___
FINDINGS:
The tip of the endotracheal tube projects over the mid thoracic trachea. A
nasogastric tube projects over the stomach. The tip of a right PICC projects
over the cavoatrial junction. Atelectasis is noted in the left midlung zone
unchanged. No large pneumothorax.
IMPRESSION:
The tip of the endotracheal tube projects over the mid thoracic trachea.
Otherwise no significant interval change since prior.
Radiology Report
EXAMINATION: Portable chest x-ray
INDICATION: ___ year old woman with SDH// New NGT please assess placement
TECHNIQUE: Portable chest x-ray
COMPARISON: Portable chest x-ray from ___
FINDINGS:
The tip of the nasogastric tube is within the stomach. The tip of the right
PICC projects over the cavoatrial junction. Subsegmental atelectasis is again
noted in the left midlung. The heart and mediastinal structures cannot
adequately be assessed secondary to patient obliquity. The aorta is
atherosclerotic.
IMPRESSION:
The tip of the endotracheal tube is within the stomach. Lungs appear
unchanged.
Radiology Report
EXAMINATION: Portable chest x-ray
INDICATION: ___ year old woman with NG tube, got pulled out slightly and
replaced// evaluate NG tube placement
TECHNIQUE: Portable supine chest x-ray
COMPARISON: Previous portable chest x-ray from ___.
FINDINGS:
The NG tube descends below the left hemidiaphragm, the tip is not seen. The
tip of the right PICC projects over the cavoatrial junction. The heart and
medius structures cannot be adequately assessed secondary to patient
obliquity. The aorta is atherosclerotic. Subsegmental atelectasis is again
noted in the left midlung.
IMPRESSION:
The NG tube descends below the left hemidiaphragm, the tip is not imaged.
Cardiomegaly. Subsegmental atelectasis left midlung.
Radiology Report
EXAMINATION: Portable chest x-ray
INDICATION: ___ year old woman with NG tube, need to confirm placement. Tip
not see in CXR just done// evaluate NG tube placement
TECHNIQUE: Semi-erect portable chest x-ray
COMPARISON: Previous supine chest x-ray from earlier in the same day, less
than 1 hour previous
FINDINGS:
The NG tube tip is seen within the stomach. The uppermost aspect of the chest
is not visualized. Within that limitation, there is no significant change
when compared to the prior study.
IMPRESSION:
NG tube tip is seen in the stomach.
Radiology Report
INDICATION: ___ year old woman with subduiral hematoma// dobhoff
TECHNIQUE: Portable chest x-ray semi erect
COMPARISON: None
FINDINGS:
The chest and upper abdomen are imaged. The tip of the top of tube is coiled
within the stomach. The right PICC tip overlies the cavoatrial junction.
Patient obliquity precludes adequate evaluation of the heart and mediastinal
structures. Subsegmental atelectasis is noted in the mid-lungs.
IMPRESSION:
The Dobhoff tube is coiled within the stomach. Subsegmental atelectasis
midlung spared
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: NGT in good position?// s/p NGT placement
TECHNIQUE: Single frontal view of the chest
COMPARISON: Multiple prior radiographs, most recently on ___ at
15:46
FINDINGS:
A enteric tube passes below the diaphragm and into the stomach, the very
distal tip of which is not visualized, however the side port is in the left
upper quadrant, likely in the stomach. A central venous catheter terminates
at the cavoatrial junction. There is mild atelectasis at the lung bases and
in the left midlung. No new focal consolidation. No pleural effusion or
pneumothorax.
IMPRESSION:
The very distal tip of an enteric tube is not visualized, however the side
port terminates within the stomach.
Radiology Report
EXAMINATION: BILAT LOWER EXT VEINS
INDICATION: ___ year old woman with h/o DVT/PE, now with TBI and holding
anticoagulation// evaluate for DVT
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the bilateral lower extremity veins.
COMPARISON: None.
FINDINGS:
There is normal compressibility, flow, and augmentation of the bilateral
common femoral, femoral, and popliteal veins. Normal color flow is
demonstrated in the posterior tibial and peroneal veins.
There is normal respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
No evidence of deep venous thrombosis in the right or left lower extremity
veins.
Radiology Report
EXAMINATION: ABDOMEN US (COMPLETE STUDY)
INDICATION: ___ year old woman with RUQ discomfort// evaluate for biliary
obstruction
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: None.
FINDINGS:
LIVER: The hepatic parenchyma appears within normal limits. The contour of
the liver is smooth. There is no focal liver mass. The main portal vein is
patent with hepatopetal flow. There is no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. The CHD measures 6 mm.
GALLBLADDER: Cholelithiasis without gallbladder wall thickening.
PANCREAS: The imaged portion of the pancreas appears within normal limits,
without masses or pancreatic ductal dilation, with portions of the pancreatic
tail obscured by overlying bowel gas.
SPLEEN: Normal echogenicity, measuring 12.7 cm.
KIDNEYS: The right kidney measures 10 cm. The left kidney measures 10.2 cm.
Echogenic foci in right renal pelvis but more than typically seen with stones.
There is a cystic lesion in the upper pole of the right kidney. There is no
evidence of masses or hydronephrosis in the kidneys.
IMPRESSION:
1. Cholelithiasis without signs of obstruction.
2. Echogenic foci in right renal pelvis possibly resulting from
nephrocalcinosis.
3. Right renal cyst.
Radiology Report
INDICATION: Status post NGT-placement. Tube in good position?
TECHNIQUE: Portable supine abdominal radiograph was obtained.
COMPARISON: Portable chest from ___ through ___
FINDINGS:
An NG tube projects over the left upper quadrant with its tip and side-port
within the stomach. PICC line is seen with its tip projecting over the
cavoatrial junction. There are no abnormally dilated loops of large or small
bowel.
Supine assessment limits detection for free air; there is no gross
pneumoperitoneum.
Osseous structures are unremarkable.
There are no unexplained soft tissue calcifications or radiopaque foreign
bodies.
IMPRESSION:
NG tube is seen with its tip and side-port within the stomach.
Radiology Report
Portable chest x-ray
Indication: PICC line placement
TECHNIQUE:
Portable chest x-ray
COMPARISON: Previous portable chest x-ray from ___
FINDINGS:
The study is compromised secondary to patient obliquity. The PICC line tip
overlies the right atrium. The enteric tube has been removed. Heart size is
difficult to assess given patient positioning. Subsegmental atelectasis is
seen in the left midlung. There are no large pleural effusions.
IMPRESSION:
PICC tip overlies the right atrium. If the desired location is the SVC
repositioning by 2 cm is advised.
Subsegmental atelectasis left midlung.
Radiology Report
EXAMINATION: Chest radiograph.
INDICATION: ___ year old woman s/p dobhoff placement. Assess position.
TECHNIQUE: Single portable semi upright frontal chest radiograph.
COMPARISON: Chest radiograph ___.
FINDINGS:
Slightly limited evaluation due to patient rotation. The lungs are moderately
well inflated with persistent bibasilar opacities. Mild cephalization of
vasculature noted. Heart is top-normal in size and partially obscured due to
patient positioning and overlying parenchymal abnormality. Persistent small
left pleural effusion. No large right pleural effusion. No pneumothorax.
An enteric feeding tube courses below the left hemidiaphragm with tip out of
field of view. A right PICC tip is within the right atrium.
IMPRESSION:
1. Right PICC tip in right atrium.
2. Vascular congestion with persistent small left pleural effusion.
RECOMMENDATION(S): Consider withdrawing right PICC 2 cm for better
positioning in the SVC.
NOTIFICATION: The findings were discussed with ___, M.D. by ___,
M.D. on the telephone on ___ at 7:24 pm, 5 minutes after discovery of
the findings.
Radiology Report
EXAMINATION: Portable chest x-ray
INDICATION: s/p NGT placement// NGT in good position?
TECHNIQUE: Portable chest x-ray
COMPARISON: Previous portable chest x-ray from ___ approximately 2
hours prior
FINDINGS:
The upper third of the chest is not included on the radiograph. The NG tube
tip is within the stomach. The side-port is also evident within the stomach.
Bibasilar opacities are grossly unchanged. Heart size cannot be adequately
assessed given patient positioning.
IMPRESSION:
NG tube tip is within the stomach.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: s/p NGT placement// NGT in good position?
IMPRESSION:
In comparison with the study of ___, the nasogastric tube has been
advanced so that the tip extends at least to the midportion of the stomach.
Streaks of atelectasis are seen in the mid and lower zones, but no evidence of
acute pneumonia or vascular congestion.
Radiology Report
INDICATION: ___ year old woman with displaced NGT// Evaluate for proper
dobhoff placement
TECHNIQUE: AP portable chest radiograph
COMPARISON: ___ from earlier in the day
FINDINGS:
The enteric tube has been removed. The tip of the right PICC line projects
over the cavoatrial junction. Atelectasis noted in the left midlung and left
lung base. No pneumothorax or large pleural effusion. The size of the
cardiac silhouette is enlarged but unchanged.
IMPRESSION:
Interval removal of the enteric tube. Otherwise no significant interval
change.
Radiology Report
INDICATION: ___ year old woman with dobhoff displaced// Please evaluate for
dobhoff placement
TECHNIQUE: AP portable chest radiographs
COMPARISON: ___ from earlier in the day
FINDINGS:
Sequential images demonstrate advancement of a Dobhoff into the stomach. The
tip of the right PICC line projects over the cavoatrial junction.
Atelectasis is noted within the left midlung zone and left lung base. There
is no pleural effusion or pneumothorax identified. The size of the cardiac
silhouette is unchanged.
IMPRESSION:
Sequential images demonstrate advancement of a Dobhoff into the stomach.
Radiology Report
INDICATION: ___ year old woman with c difficile now with abdominal pain.
Evaluate for obstruction, perforation.
TECHNIQUE: Portable supine abdominal radiograph was obtained.
COMPARISON: Abdominal ultrasound ___.
FINDINGS:
Limited abdominal radiograph due to portable technique and body habitus.
Nonspecific bowel gas pattern.
Arteriovascular calcifications.
No acute osseus abnormality. Osteopenia.
IMPRESSION:
Limited study. Nonspecific bowel gas pattern.
Radiology Report
EXAMINATION: DX PELVIS AND HIP UNILATERAL
INDICATION: ___ year old woman with R hip pain.// Fracture?
COMPARISON: None.
FINDINGS:
Assessment of fine bony detail is limited by background osteopenia and
overlying soft tissues, with underpenetration. Allowing for this, no lucent
or sclerotic fracture line or displaced fracture fragment is detected in the
right proximal femur or about the right hip. There is intracortical tunneling
in the proximal femur consistent with osteoporosis. There is mild
degenerative change of the right hip joint, with mild joint space narrowing
and marginal spurring.
Assessment of the left hip is quite limited on this single AP view,, but shows
similar mild degenerative change.
The pelvic girdle remains grossly congruent, with degenerative changes of both
SI joints. Extensive vascular calcifications noted.
IMPRESSION:
No obvious fracture detected involving the right hip. However, given the
degree of osteoporosis, if there is high clinical suspicion for nondisplaced
fracture, then MRI or CT could help for further assessment
Mild right and left hip degenerative changes and degenerative changes of both
SI joints.
Dense vascular calcification.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old woman s/p bilateral subdural hematomas now change in
level of consciousness. Evaluate for acute hemorrhage.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 5.0 s, 20.0 cm; CTDIvol = 46.7 mGy (Head) DLP =
934.2 mGy-cm.
Total DLP (Head) = 934 mGy-cm.
COMPARISON: Noncontrast CT head performed ___.
FINDINGS:
Right mixed-density subdural hematoma and smaller left mixed-density,
predominantly hypodense subdural hematoma have both decreased in size since ___. Small residual parafalcine subdural hematoma is are slightly
smaller. Previously seen paratentorial subdural blood is no longer visualized
on axial images. There is no new hemorrhage. Sulcal effacement has
essentially resolved. Lateral and third ventricles have re-expanded. Mass
effect on the midbrain has substantially improved. There is no CT evidence
for an acute major vascular territorial infarction.
No suspicious bone lesion is seen. Again demonstrated are bilateral mucous
retention cysts in the maxillary sinuses. Nasogastric tube is again seen in
the left naris. Mastoid air cells are grossly clear allowing for absence of
dedicated bone algorithm images.
IMPRESSION:
1. Decreased bilateral mixed density subdural hematomas compared to ___ with near complete resolution of sulcal effacement, re-expansion of the
lateral and third ventricles, and substantially improved mass effect on the
midbrain.
2. No evidence for new intracranial abnormalities.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: SDH, Transfer
Diagnosed with Nontraumatic subdural hemorrhage, unspecified
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: intubated
level of acuity: 1.0 | ___ yo F c a PMH significant for pulmonary embolism on coumadin,
T2DM, CAD, COPD/asthma and rheumatoid arthritis now admitted
with bilateral subdural hematomas.
# bilateral subdural hematomas
Mrs. ___ was admitted intubated and mechanically ventilated
with bilateral subdural hematomas. Her therapeutic
anticoagulation with coumarin had been reversed at an outside
hospital. She was started on a 7 day course of levetiracetam for
seizure prophylaxis. Serial CT heads showed stable subdural
hematomas and she was successfully extubated and transferred to
the Medicine ward. Blood pressure control was achieved with
Labetalol and Amlodipin. Aspirin was restarted. The therapeutic
anticoagulation with coumadin for DVTs was held as per
recommendation of neurosurgery and safety to restart it will be
reassessed during her appointment in the ___ clinic in
2 weeks. Mrs. ___ needs to follow up with Dr. ___ in
the ___ clinic in 2 weeks.
# recurrent DVTs
As per PCP the patient had recurrent DVTs in the past when she
was taken off coumadin. She does not have a history of PE.
Bilateral ultrasound of the leg veins on ___ did not show
evidence of DVT. The therapeutic anticoagulation with coumadin
for DVTs was held as per recommendation of neurosurgery and
safety to restart it will be reassessed during her appointment
in the ___ clinic in 2 weeks.
# episode of temporary decrease in LOC on ___
Mrs. ___ level of consciousness temporarily dropped from GCS
15 to GCS 9 on ___. BGL was normal and the patient was not at
any sedatives that would be able to explain the change in mental
status. A CT head showed resolving bilateral SDH but no new
findings. Hypoactive delirium was considered as a potential
explanation but we also considered the possibility of a
non-convulsive seizure. Our plan was to obtain an EEG in case of
recurrence.
#HTN
To obtain blood pressure control with a target systolic BP < 160
we started the patient on labetalol and amlodipine. Metoprolol
was discontinued. At the time of discharge the patients was
predominantly well controlled and in above mentioned target rate
on amlodipine 10 mg PO OD and labetalol 300 mg PO TID.
# C.diff positive diarrhea
Mrs. ___ developed Clostridium difficile positive diarrhea.
She was started on PO Vancomycin on ___. The diarrhea had been
c/b pre-renal ___ which resolved with strict I/O and fluid
repletion. She continues to have loose stool at time of
discharge. We recommend to continue PO Vancomycin for 2 weeks
after completion of ceftazidime for UTI.
# E.coli UTI
She was found to have a positive UA with associated altered
mental status. Given resistance pattern, ceftazidime for E.
coli UTI. Start date ___. End date for a 7 day course on ___.
# swallowing assessment
After liberation from mechanical ventilation the patient was
assessed by speech/swallow service and found to have dysphagia.
After tube feedings for multiple days she was cleared for oral
food intake. Current recommendations of the speech/swallow
service are:
1. PO diet: nectar thick liquids, ground solids
2. PO meds: crushed in pureed solids
3. TID oral care
4. Aspiration precautions:
- strict 1:1 assist
- alternate bites and sips to clear pharyngeal residue
- swallow twice for solids
- ensure fully upright and ALERT for entire meal
5. Recommend continuation of tube feeds until pt able to meet
nutritional needs via POs alone. Appreciate RD input to manage
tube feeds to encourage POs.
# ___
Mrs. ___ met criteria for ___ twice during her
hospitalization. Her creatinine was 1.2 mg/dl on admission and
went up to 1.8 mg/dl during her stay in the ICU. The creatinine
subsequently resolved. In the setting of C. diff positive
diarrhea she developed ___ again with a peak creatinine level of
1.6. The ___ resolved with fluid repletion, strict I/O and
avoidance of nephrotoxic drugs. Cr. was 1.3 at the time of
discharge. It should continue to be trended at rehab.
# hypercalcemia
Peak corrected total calcium 10.7 likely secondary to
immobilization.
# R hip pain
An x-ray of the R hip was done as the patient had c/o R hip
pain. It did not show a fracture but showed severe osteoporosis.
She frequently reported that these pains were chronic. If she
continues to complain of this pain, could consider repeat
imaging.
# physical exam findings c/f movement disorder
Mrs. ___ had shown at times physical exam findings (tremor,
cogwheel rigidity) that raised the concern of a movement
disorder. Outpatient evaluation is recommended.
# CAD
continued on ASA 81 mg PO OD and atorvastatin
# T2DM
Patient on basal-bolus regime with insulin glargine and sliding
scale insulin. She was on regular insulin Q6H when receiving
tube feeds.
# confusion
- continued on risperidone |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / CellCept
Attending: ___.
Chief Complaint:
weakness, fatigue, altered mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HISTORY OF PRESENT ILLNESS:
___ year old female with PMH of ESRD on dialysis ___, HTN, h/o
seizure in setting of missing dialysis, chronic pleural
effusion,
referred by PCP ___ 3 weeks of weakness, fatigue and altered
mental status.
At the office visit, the patient's husband described the patient
has become increasingly lethargic and forgetful over the last
three weeks. She has had distinct episodes lasting about one
hour
during which she is confused and "not herself." He describe The
episodes lasted approximately one hour at a time, but since
___ she has consistently unable to express herself. She has
also become weak, becoming more dependent on her rollator for
walking. In the office, she had no focal neurologic deficits on
exam, was hypertensive to 190/80.
The patient and husband deny fevers, chills, chest pain,
shortness of breath. They do report that she has had more
intermittent loose stool. No blood in the stool.
Her blood pressure had been uncontrolled; she was hypertensive
at
dialysis ___ with systolic blood pressures over 200. The patient
was unsure whether she took her medications that morning, so her
husband brought in her medications, and she took them at
dialysis. Her blood pressure went down appropriately.
In the emergency room she coughed and spit up po hydralazine.
In the ED, initial VS were: 98.5 69 193/63 18 98% RA
Exam notable for: Cranial nerves II -XII intact, 5 out of 5
strength bilaterally upper and lower extremities, full sensation
bilaterally
ECG: sinus, nl intervls, no st-twave changes, LVH by criteria,
Labs showed: PLT 78, no leukocytosis, H/H baseline, Ca ___, BUN
22, Cr 4.7
Imaging showed: CT head with no acute intracranial process, CXR
Blunting of the right posterior costophrenic angle is compatible
with right lung base rounded atelectasis seen on prior CT.
Consults: none
Patient received: IV hydralazine
Transfer VS were: 98.1 68 183/68 18 100% RA
On arrival to the floor, patient with difficulty piecing
together
sentences. Per husband, this has been constant since ___. She
does not find this frustrating. She complains of hand soreness.
Husband states she has not been able to take her atorvastatin,
aspirin, lisinopril for the past three weeks. She usually is
unsupervised taking her medications. He believes she has missed
doses at least twice this week of her carvedilol.
REVIEW OF SYSTEMS: 10 point ROS reviewed and negative except as
per HPI
Past Medical History:
- ESRD on HD ___ s/p failed living related-donor kidney
transplant due to inability to tolerate cellcept; listed for
repeat transplant at ___
- Chronic right pleural effusion (lymphocyte-predominant) and
mediastinal/hilar lymphadenopathy s/p EBUS biopsy ___
- HFpEF
- HTN c/b hypertensive emergency ___
- Seizure in setting of missed dialysis ___
- Anemia of chronic disease
- Lactose intolerance
- Shingles
- Ovarian cyst
- Previous falls c/b rib fractures -- posterior left ___ and 6th
ribs fractured; lateral left ___ rib fractures ___.
- Low transverse cesarean section ___
- LUE AV fistula (___) ___
- CCY
- Living Related-Donor Kidney Transplant
Social History:
___
Family History:
Significant for Mother: HTN, stroke in ___.
Physical Exam:
ADMISSION PHYSICAL EXAM
=========================
VS: 196 / 69 68 18 98 RA
GENERAL: NAD, laying comfortably in bed, very pleasant
HEENT: AT/NC, anicteric sclera, MMM
NECK: supple, no LAD
CV: RRR, S1/S2, no murmurs, gallops, or rubs
PULM: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
GI: abdomen soft, nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no edema
NEURO: Alert, cannot say where she is, does say yes when
hospital
is named, oriented to person, date. CN II-XII intact. ___
strength in ___ bilaterally. Sensation grossly intact.
Rigidity
in B/L UE. Reflexes deferred. Gait not observed. does not follow
commands to completion. FTN extremely slow movement, will
approach but not make contact with finger.
DERM: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM:
==========================
___ Temp: 98.6 PO BP: 171/54 HR: 67 RR: 18 O2 sat: 99% O2
delivery: RA weight 57.6kg
GENERAL: Sitting in bed, pleasant, NAD
HEENT: AT/NC, anicteric sclera, MMM
CV: RRR, S1/S2, III/VI systolic ejection murmur heard best at
the
USB
PULM: CTAB
EXTREMITIES: No extremity edema.
NEURO: AOx3. Fluent speech. MoCA ___
___ strength on delt, 4+/5 on quads, ___ on TA bilaterally.
Rigidity improved in the UE, barely there. Sensation grossly
intact. 2+ reflex throughout. No clonus. Gait not observed.
DERM: warm and well perfused.
Pertinent Results:
ADMISSION LABS
===============
___ 11:23PM ___ PTT-30.1 ___
___ 06:30PM GLUCOSE-83 UREA N-22* CREAT-4.7* SODIUM-140
POTASSIUM-4.7 CHLORIDE-96 TOTAL CO2-31 ANION GAP-13
___ 06:30PM estGFR-Using this
___ 06:30PM ALT(SGPT)-11 AST(SGOT)-18 ALK PHOS-91 TOT
BILI-0.7
___ 06:30PM ALBUMIN-3.9 CALCIUM-10.7* PHOSPHATE-4.3
MAGNESIUM-2.4
___ 06:30PM VIT B12-247
___ 06:30PM TSH-3.1
___ 06:30PM WBC-5.4 RBC-2.87* HGB-9.6* HCT-29.2* MCV-102*
MCH-33.4* MCHC-32.9 RDW-15.9* RDWSD-59.4*
___ 06:30PM NEUTS-51.3 ___ MONOS-15.0* EOS-8.7*
BASOS-0.7 IM ___ AbsNeut-2.77 AbsLymp-1.30 AbsMono-0.81*
AbsEos-0.47 AbsBaso-0.04
___ 06:30PM PLT COUNT-78*
ADMISSION IMAGING
==================
CT HEAD WITHOUT CONTRAST ___
IMPRESSION:
1. No acute intracranial process.
2. Interval improvement in opacification of the left mastoid air
cells and
left middle ear cavity.
MRI HEAD WITHOUT CONTRAST ___
IMPRESSION:
1. Interval progression since ___ of bilateral,
confluent
periventricular and subcortical white matter T2/FLAIR
hyperintensities with
involvement of the splenium of the corpus callosum. Given
appearance, this
patient's age, and prior presentations of hypertension, findings
are favored
to represent subcortical leukoencephalopathy/small vessel
dementia/Binswanger
disease.
2. No acute intracranial infarction or hemorrhage.
3. Global involutional changes
EEG ___
IMPRESSION: This is an abnormal continuous ICU EEG monitoring
study because
of moderate diffuse background slowing, slow posterior dominant
rhythm and
frequent runs of frontal intermittent rhythmic delta activity
(FIRDA). These
findings are indicative of moderate diffuse cerebral
dysfunction, which is
nonspecific as to etiology. Common causes include infection,
medication
effects, and toxic-metabolic encephalopathies. FIRDA can also be
seen with
deep midline structural lesions, hydrocephalus, increased
intracranial
pressure, and brain stem lesions. There are no focal
abnormalities,
epileptiform discharges, or electrographic seizures.
DISCHARGE LABS
===============
___ 06:15AM BLOOD Glucose-86 UreaN-41* Creat-5.0*# Na-137
K-4.8 Cl-99 HCO3-23 AnGap-15
INTERVAL LABS
==================
___ MMA 740
___ B1 pending
___ intrinsic factor pending
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 10 mg PO DAILY
2. Atorvastatin 10 mg PO QPM
3. Calcitriol 1 mcg IV Frequency is Unknown with dialysis
4. Carvedilol 25 mg PO BID
5. Epoetin Alfa 5000 UNIT IV Frequency is Unknown with dialysis
6. HydrALAZINE 25 mg PO TID:PRN BP >180
7. Lisinopril 40 mg PO DAILY
8. sevelamer CARBONATE 800 mg PO TID W/MEALS
9. Aspirin 81 mg PO DAILY
10. Nephrocaps 1 CAP PO DAILY
11. diclofenac sodium 1 % topical 3X/WEEK wrist after dialysis
Discharge Medications:
1. HydrALAZINE 100 mg PO Q8H
2. amLODIPine 10 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 10 mg PO QPM
5. Calcitriol 1 mcg IV WITH HD with dialysis
6. Carvedilol 25 mg PO BID
7. diclofenac sodium 1 % topical 3X/WEEK (___) wrist after
dialysis
8. Epoetin Alfa 5000 UNIT IV ONCE with dialysis Duration: 1
Dose
9. Lisinopril 40 mg PO DAILY
10. Nephrocaps 1 CAP PO DAILY
11. sevelamer CARBONATE 800 mg PO TID W/MEALS
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
#Small vessel ischemic disease
#MAHA
#B12 deficiency
#Thrombocytopenia
#Uncontrolled hypertension
Discharge Condition:
Patient is stable. She is alert and oriented x3. She is able to
ambulate with a walker.
Followup Instructions:
___
Radiology Report
INDICATION: ___ with ams, weakness// ?pneumonia
TECHNIQUE: AP and lateral views the chest.
COMPARISON: X-ray from ___. Chest CT from ___.
FINDINGS:
Patient is rotated to the right. Blunting of the right posterior costophrenic
angle is compatible with right lung base rounded atelectasis seen on prior CT.
The lungs are otherwise grossly clear. Cardiomediastinal silhouette is
stable. No acute osseous abnormalities, chronic deformities of posterior left
ribs are noted.
IMPRESSION:
No definite acute cardiopulmonary process.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ with hypertension and encephalopathy// ?bleed
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal reformations as well as bone algorithm
reconstructions were provided and reviewed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 16.0 s, 16.0 cm; CTDIvol = 50.2 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: MR head ___, CT head ___
FINDINGS:
There is no evidence of acute infarction,hemorrhage,edema, or mass. Again seen
is confluent bilateral periventricular and subcortical white matter
hypodensities which are nonspecific, likely the sequelae of chronic small
vessel ischemic disease. There is prominence of the ventricles and sulci
suggestive of involutional changes.
There is no evidence of fracture. A left parietal osteoma is seen. There is
decreased opacification of the left mastoid air cells. The visualized portion
of the paranasal sinuses, right mastoid air cells, and middle ear cavities are
clear. The visualized portion of the orbits are unremarkable.
IMPRESSION:
1. No acute intracranial process.
2. Interval improvement in opacification of the left mastoid air cells and
left middle ear cavity.
Radiology Report
EXAMINATION: MR HEAD W/O CONTRAST T___ MR HEAD.
INDICATION: ___ year old woman with expressive aphasia, word finding
difficulties, subacute presentation// eval for CVA, PRES, amyloid angiopathy.
TECHNIQUE: Sagittal T1 weighted imaging was performed. Axial imaging was
performed with gradient echo, FLAIR, diffusion, and T2 technique were then
obtained.
COMPARISON
1. MR head ___.
2. MR head ___.
FINDINGS:
Limited exam due to patient motion on multiple sequences. Within limitation:
again seen are bilateral white matter T2/FLAIR hyperintense signal
abnormalities. Although the majority of these are periventricular in
distribution and confluent, there are additional areas of focal and confluent
subcortical white matter involvement worst in the left frontal lobe but also
involving the left parietal lobe and right frontal and parietal lobes (for
example see series 9 images 16, 15, and 14). Additionally, there is T2/FLAIR
signal abnormality involving much of the splenium of the corpus callosum
(09:12). These findings are progressed from prior studies of ___.
There is no evidence of acute intracranial infarction, hemorrhage, mass, or
mass effect, although note the GRE images are degraded by motion. Prominence
of the ventricles and sulci is stable and consistent with global involutional
changes. The major intracranial vascular flow voids are grossly preserved.
There is a cavum septum pellucidum, a normal anatomic variant. The globes are
unremarkable.
IMPRESSION:
1. Interval progression since ___ of bilateral, confluent
periventricular and subcortical white matter T2/FLAIR hyperintensities with
involvement of the splenium of the corpus callosum. Given appearance, this
patient's age, and prior presentations of hypertension, findings are favored
to represent subcortical leukoencephalopathy/small vessel dementia/Binswanger
disease.
2. No acute intracranial infarction or hemorrhage.
3. Global involutional changes.
Gender: F
Race: AMERICAN INDIAN/ALASKA NATIVE
Arrive by WALK IN
Chief complaint: Altered mental status, Weakness
Diagnosed with Altered mental status, unspecified
temperature: 98.5
heartrate: 69.0
resprate: 18.0
o2sat: 98.0
sbp: 193.0
dbp: 63.0
level of pain: 0
level of acuity: 2.0 | ___ year old female with PMHx of ESRD on dialysis ___, HTN, h/o
seizure in setting of missing dialysis, chronic pleural
effusion, referred by PCP ___ 3 weeks of weakness, fatigue and
altered mental status and expressive aphasia.
At the office visit, the patient's husband described the patient
has become increasingly lethargic and forgetful over the last
three weeks. She has had distinct episodes lasting about one
hour during which she is confused and "not herself." He describe
the episodes lasted approximately one hour at a time, but since
___ she has consistently unable to express herself. She has
also become weak, becoming more dependent on her rollator for
walking. In the office, she had no focal neurologic deficits on
exam, was hypertensive to 190/80. She was also noted to be
hypertensive at her HD session on ___ with SBP >200. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Weakness, abdominal distention
Major Surgical or Invasive Procedure:
___: Exploratory laparotomy, excision of subcutaneous
metastases and ileocolic bypass
History of Present Illness:
___ year old woman with uterine leiomyosarcoma metastatic to lung
s/p surgery and adjuvant XRT who has very aggressive disease
that
was noted to progress even while receiving XRT, s/p 8 cycles of
Gemcitabine/Docetaxol, recent progression noted ___,
currently
on AIM C2D14. Patient was discharged one week ago after being
admitted from ___ to ___ with a SBO secondary to a large pelvic
mass which is inoperable, s/p PEG placement for decompression.
Patient reports that she was feeling fairly well on discharge
one
week ago but a couple of days later slowly started feeling weak
and this progressed to the point where she had difficulty
walking. No focal weakness rather weakness in her muscles and
fatigue. No DOE, no SOB. No cough. No CP. No palpitations.
No headache. Had dizziness when rising from a seated position.
Reports that she has not been taking any PO other than liquids
and no medications other than sucralfate. She feels that she
can
not swallow pills because despite drinking lots of fluids her
throat is dry. She notes that she has had increase in
pelvic/abdominal pain that is of the same quality as prior. No
new sites of pain. She was not taking pain medication at home;
at the present she has no pain after receiving Dilaudid in the
ED. No stool from rectum. No N/V. No problems with PEG. Has
been getting TPN at night. Normal UOP. No dysuria. No URI sx.
Reports feeling improved since treatment in the ED.
REVIEW OF SYSTEMS is negative in detail other than as noted
above
and frequent heartburn.
Past Medical History:
OBGYNHx: Gravida 0. Menopausal symptoms of hot flashes for ___
year. Has a history of fibroids. No hx of ovarian cysts, STD's
or
abnormal pap smears. Last pap was in ___ and was normal.
Mammogram in ___ was nml.
PMH: Denies history of asthma, heart disease, diabetes, HTN,
thromboembolic disease and breast cancer.
PSH: Open cholecystectomy in ___
Past Oncological History:
___: Initiated a 9 month period of amenorrhea
-___: Menstrual cycle recommenced with flow similar
to
her previous menstrual cycles. However, as the days went by,
she began experiencing menorrhagia with large blood clots the
size of a tennis ball.
-___: ___ Emergency department. She
underwent a transvaginal ultrasound that showed an 8 x 11 x 9.2
cm uterus with a complex cystic mass in the central uterus
measuring 7.5 x 4.5 cm with multiple septations. She also
underwent a biopsy of the cervix in the emergency department
with
pathology revealing poorly differentiated pleomorphic malignant
neoplasm likely pleomorphic leiomyosarcoma, positive focally for
caldesmon, P16, KI67 increased and negative for melcam, AE1/3,
EMA, P53, P63, inhibin, GATA-3, MelanA, HMB-45, ERG, CD34.
-___: Evaluated by her gynecologist in the office,
Dr. ___. MRI showed a complex 8.2 x 8.8 cm mass.
-___: Established care with Dr. ___. Pelvic exam
revealed the cervix with foul-smelling necrotic tissue, and a
biopsy was performed in clinic.
-___: CT chest, abdomen and pelvis that showed
suspicious left external iliac lymph nodes, two 7 mm periaortic
lymph nodes, a 3-mm left lower lobe nodular atelectasis and a
15.5 x 10.9 x 9.9 cm mass around the lower uterus.
-___: Total abdominal hysterectomy, bilateral
salpingo-oophorectomy, bilateral lymph node sampling, cystoscopy
and omental biopsy. Intraoperatively, the mass extended to the
bilateral pelvic sidewalls with large external bilateral iliac
lymph nodes and a normal omentum.
**PATH: 9.5 cm mass consistent with leiomyosarcoma with
lymphovascular invasion, positive for desmin and ER/PR negative.
The vagina also had fragments of leiomyosarcoma, zero out of
three lymph nodes were positive, but there was involvement of
perinodal fat with leiomyosarcoma. The peritoneal washings were
negative.
-___: Adjuvant radiation therapy started with ___
in ___
-___: CT imaging at ___'s office showed nodules in lung
-___: CT Torso:
*Interval development of multifocal,
multilobuated,heterogeneously -enhancing mass in the pelvis
containing cystic and soft tissue
components with pelvic wall lymphadenopathy, concerning for
disease recurrence.
*Moderate hydroureteronephrosis on the left kidney secondary to
mass effect from above lesion.
*Multiple new pulmonary nodules, predominantly in the lower
lobes
consistent with metastatic disease.
-___: C1D1 Gemcitabine/docetaxel started
-___: C1D8 Docetaxel allergic reaction manifested
as cp, flushing, and dyspnea which resolved with steroids and
benadryl.
-___ to ___ with slow infusion of
docetaxel, well-tolerated
Social History:
___
Family History:
Denies family hx of cancer, heart disease, DM
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VITAL SIGNS: T 98 BP 126/84 HR 118 RR 20 SpO2 96% 3L
General: Fairly well-appearing woman in NAD.
HEENT: NC/AT, constricted pupils, alopecia, MMM, no OP lesions,
no cervical, supraclavicular, or axillary adenopathy, no
thyromegaly
CV: RR, tachycardic, NL S1S2 no MRG
PULM: decreased breath sounds bilaterally at the bases, no
rales
or wheezing
ABD: markedly hypoactive bowel sounds, hard mass appreciated in
the pelvis particularly around area of previous surgical
incision, no fluid wave appreciated, no tenderness to palpation
LIMBS: warm, well-perfused, no calf ttp, no edema
SKIN: No rashes or skin breakdown
NEURO: A&OX3, CN II-XII intact (visual acuity not tested),
proximal/distal strength ___ X 4 extremities, sensation grossly
intact
DISCHARGE PHYSICAL EXAM:
========================
General: doing well, tolerating a regular diet, pain controlled
by pain medications by mouth.
VSS
Neuro: A&OX3
Cardio/pulm: no chest pain, no resp distress
Abd: soft, nontender, surgical site intact.
Pertinent Results:
ADMISSION LABS:
===============
___ 04:30PM BLOOD WBC-4.8 RBC-3.62*# Hgb-8.7*# Hct-27.4*
MCV-76* MCH-23.9* MCHC-31.7 RDW-16.2* Plt Ct-60*#
___ 04:30PM BLOOD Glucose-142* UreaN-51* Creat-1.2* Na-140
K-2.4* Cl-76* HCO3-GREATER TH
___ 10:05PM BLOOD ALT-123* AST-95* AlkPhos-192* TotBili-0.3
___ 04:30PM BLOOD Calcium-9.0 Phos-4.4# Mg-2.7*
___ 06:34PM BLOOD Lactate-2.7*
DISCHARGE LABS:
===============
MICRO:
======
- PRELIM BLOOD CX FROM ___: GNRs in ___ bottles, pending.
- Blood Cultures: No growth, pending.
- Urine Cultures: No growth, pending.
- C. diff PCR: NEGATIVE
RELEVANT STUDIES:
=================
- CT CHEST W/ CONTRAST (___):
1. Numerous pre-existing pulmonary metastases demonstrate a
mixed response to treatment, with some lesions demonstrating
complete resolution, many lesions showing a decrease in size,
and a small minority of lesions demonstrating interval growth.
2. Partially imaged upper abdomen shows new dilatation of
multiple proximal small bowel loops unclear etiology. For a more
detailed discussion of the upper abdomen, please refer to the
separate report from the CT abdomen/pelvis performed
concurrently.
3. Healing left tenth rib fracture
- CT ABDOMEN W/ CONTRAST (___):
1. Worsening dilatation of the small bowel loops with numerous
air-fluid levels and collapsed colon consistent with small bowel
obstruction. The transition point is not included on this study
but was seen to be at the level of the pelvic mass on the pelvic
MRI.
2. Unchanged size of a ___ nodule in the anterior
abdominal wall measuring 3.6 x 5.4 cm the last exam, but
increased since ___ exam.
3. Hypo attenuating liver consistent with hepatic steatosis.
4. No new metastatic lesions are seen in the abdomen. For
details regarding the pelvis please see pelvic MRI dated ___ and for details regarding the chest see dedicated
chest CT report.
- MRI PELVIS (___):
1. Progressive increase in size of the dominant cystic pelvic
tumor, as well as the ___ nodule. No new
metastatic disease identified within the pelvis.
2. Progressive dilatation of chronically obstructed small bowel
loops.
- EKG (___): Sinus tachycardia. Non-specific ST segment
changes diffusely. No previous tracing available for comparison.
- CXR (___): Heart size and mediastinum are stable. Multiple
pulmonary nodules a present but overall appear to be decrease in
the extent and number as compared to prior examination, may be
potentially reactive to chemotherapy. No large pleural effusion
demonstrated. No definitive focal consolidations seen. Right
Port-A-Cath catheter tip terminates at the lower SVC.
___ 06:46AM BLOOD WBC-10.0 RBC-2.74* Hgb-7.7* Hct-24.1*
MCV-88 MCH-28.0 MCHC-31.8 RDW-20.2* Plt ___
___ 11:00AM BLOOD WBC-12.5* RBC-2.93* Hgb-8.3* Hct-25.9*
MCV-88 MCH-28.5 MCHC-32.2 RDW-20.0* Plt ___
___ 05:45AM BLOOD WBC-12.4* RBC-3.09* Hgb-8.7* Hct-26.4*
MCV-86 MCH-28.1 MCHC-32.8 RDW-19.0* Plt ___
___ 06:19AM BLOOD WBC-18.7* RBC-3.13* Hgb-8.8* Hct-27.1*
MCV-87 MCH-28.1 MCHC-32.4 RDW-19.4* Plt ___
___ 08:48AM BLOOD Hgb-9.0* Hct-26.6*
___ 02:57AM BLOOD WBC-20.8* RBC-3.12* Hgb-9.0* Hct-26.8*
MCV-86 MCH-28.8 MCHC-33.5 RDW-19.2* Plt ___
___ 02:09PM BLOOD Hct-31.8*
___ 07:36AM BLOOD Hct-32.3*
___ 03:53AM BLOOD WBC-26.7* RBC-3.81* Hgb-11.0* Hct-32.6*#
MCV-85 MCH-28.8 MCHC-33.7 RDW-19.3* Plt ___
___ 06:46AM BLOOD Glucose-97 UreaN-5* Creat-0.4 Na-140
K-3.9 Cl-106 HCO3-27 AnGap-11
___ 08:10AM BLOOD Glucose-116* UreaN-12 Creat-0.4 Na-140
K-4.4 Cl-105 HCO3-28 AnGap-11
___ 05:24AM BLOOD Glucose-133* UreaN-11 Creat-0.3* Na-140
K-4.1 Cl-107 HCO3-27 AnGap-10
___ 03:46PM BLOOD Glucose-96 UreaN-8 Creat-0.3* Na-140
K-3.7 Cl-107 HCO3-27 AnGap-10
___ 07:15AM BLOOD Glucose-119* UreaN-11 Creat-0.3* Na-140
K-3.8 Cl-106 HCO3-31 AnGap-7*
___ 05:45AM BLOOD Glucose-171* UreaN-11 Creat-0.4 Na-141
K-3.2* Cl-105 HCO3-29 AnGap-10
___ 06:19AM BLOOD Glucose-128* UreaN-13 Creat-0.5 Na-139
K-4.1 Cl-104 HCO3-28 AnGap-11
___ 06:46AM BLOOD Calcium-7.7* Phos-3.6 Mg-1.9
___ 08:10AM BLOOD Albumin-2.5* Calcium-7.9* Phos-3.7 Mg-1.9
___ 05:24AM BLOOD Calcium-7.2* Phos-3.0 Mg-1.9
___ 07:15AM BLOOD Calcium-7.5* Phos-3.0 Mg-2.0
___ 05:45AM BLOOD Calcium-7.6* Phos-3.2 Mg-1.8
___ 06:19AM BLOOD Calcium-8.0* Phos-3.1 Mg-2.0
___ 02:57AM BLOOD Albumin-2.0* Calcium-7.1* Phos-2.4*#
Mg-2.0
___ 10:33PM BLOOD Lactate-1.4
___ 09:56PM BLOOD Lactate-1.6
___ 11:18AM BLOOD Lactate-2.0
___ 06:34PM BLOOD Lactate-2.7*
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Sucralfate 1 gm PO QID
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
do not give more than 3000mg of tylenol in 24 hours
RX *acetaminophen 325 mg 2 tablet(s) by mouth every six (6)
hours Disp #*45 Tablet Refills:*0
2. Heparin Flush (10 units/ml) 5 mL IV DAILY and PRN, line flush
3. Heparin Flush (100 units/ml) 5 mL IV PRN DE-ACCESSING port
4. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
hold for increased sedation or rr<12
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*50 Tablet Refills:*0
5. Sodium Chloride 0.9% Flush 10 mL IV DAILY and PRN, line
flush
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Leiomyosarcoma causing small-bowel obstruction.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with uterine sarcoma admitted with weakness and
recent history of low grade temperatures. Now with oxygen requirement. //
Please evaluate for effusions or evidence of infections, metastasis.
TECHNIQUE: CHEST (PORTABLE AP)
COMPARISON: ___
IMPRESSION:
Heart size and mediastinum are stable. Multiple pulmonary nodules a present
but overall appear to be decrease in the extent and number as compared to
prior examination, may be potentially reactive to chemotherapy. No large
pleural effusion demonstrated. No definitive focal consolidations seen.
Right Port-A-Cath catheter tip terminates at the lower SVC.
Radiology Report
EXAMINATION: MRI of the pelvis with and without contrast
INDICATION: ___ year old woman with serous ovarian cancer s/p 2 cycles
chemotherapy, C2D15 of AIM // please evaluate for interval change of cancer
burden ___ medical record reports radical hysterectomy and bilateral
salpingo-oophorectomy for high-grade leiomyosarcoma involving the lower
uterine segment and cervix, with extensive lymphatic and vascular invasion.
There has been progressive small-bowel obstruction secondary to the enlarging
pelvic mass.
TECHNIQUE: Multiplanar MRI of the pelvis is obtained at 1.5 Tesla per the
female pelvis protocol. T1 and T2 weighted sequences are acquired both pre and
post administration 7 mL of Gadavist
COMPARISON: Multiple prior pelvic and abdominal CTs dating ___ 3
most recently ___. There is a single MRI of the pelvis dating ___.
FINDINGS:
There continues to be progressive increase in size of the dominant anterior
midline cystic pelvic mass. This has current ___ of 14 x 11.6 x 12.3 cm
(increased from 11.7 x 8.7 x 10.1cm on ___. The mass is cystic
with innumerable irregular septations and enhancing nodules. It is
predominately in capsulated with several foci of extension beyond the capsule.
These excrescences are both cystic (08:13) and solid enhancing (1501:79). The
mass abuts the roof of the bladder, without macroscopic invasion.
There is been minimal interval growth of the Sister ___ nodule at the
umbilicus, now 5.5cm in transverse dimension. No additional metastatic
disease is noted within the included field of view.
There is no free pelvic fluid or lymphadenopathy. Visualized small bowel loops
are progressively dilated with multiple air-fluid levels. A transition to
completely decompressed distal ileum is again noted at the posterior right
lateral aspect of the pelvic mass.
Note is made of a new 9mm pocket of nonenhancing T1 hyperintense material
along the posterior aspect of the lower vagina just left of midline, with
surrounding ___ (___). The location is most consistent
with a Bartholin gland cyst, with potential superinfection given the
surrounding enhancement.
There is diffuse pelvic amount muscular edema as well as well as subcutaneous
edema suggestive of generalized anasarca.
IMPRESSION:
Progressive increase in size of the dominant cystic pelvic tumor, as well as
the Sister ___ nodule. No new metastatic disease identified within the
pelvis.
Progressive dilatation of chronically obstructed small bowel loops.
New, potentially infected, 9mm Bartholin gland cyst.
Radiology Report
EXAMINATION: ABD SUPINE AND LAT DECUB
INDICATION: ___ year old woman with uterine sarcoma, hx of sbo ___ mass //
signs of obstruction
TECHNIQUE: Portable radiographs of the abdomen.
COMPARISON: Correlation with CT abdomen pelvis performed ___
performed.
FINDINGS:
There are air-filled, dilated loops of small bowel seen in the abdomen.
Multiple decubitus views demonstrate air-fluid levels. These findings are
concerning for small bowel obstruction.
There are cholecystectomy clips in the right upper quadrant.
IMPRESSION:
Multiple air-filled dilated loops of small bowel with air-fluid levels,
concerning for small bowel obstruction.
NOTIFICATION: Above findings were discussed over the phone with ___
___ by Dr. ___ on ___ at 17:38
Radiology Report
INDICATION: ___ year old woman with h/o leiomyosarcoma metastatic to lung s/p
___ cycle of AIM chemotherapy // please evaluate tumor response to
chemotherapy
TECHNIQUE: CT of the abdomen
DOSE: DLP: 973 mGy-cm (abdomen.
COMPARISON: MR from ___ and CT the abdomen pelvis from ___
FINDINGS:
LOWER CHEST:
Please refer to the CT chest from the same day for full description of thorax
including multiple lung base nodules.
ABDOMEN:
The liver is diffusely hypodense compatible with hepatic steatosis. No focal
liver lesions are identified. Both kidneys are within normal limits. The
adrenal glands are normal. The pancreas is normal. No focal splenic lesions
are identified. There is no abdominal free fluid. There is no retroperitoneal
lymphadenopathy by CT criteria.
Extensive dilated loops of small bowel are found throughout the imaged portion
the abdomen measuring up to 6 cm. The colon is collapsed. The transition point
is not imaged on this CT however was imaged on the MR from ___. A
PEG tube is in place.
A 3.5 x 5.4 Sister ___ node is imaged, new since ___.
BONES AND SOFT TISSUES:
There is no evidence of worrisome lesions. Abdominal and pelvic wall is within
normal limits.
IMPRESSION:
1. Worsening dilatation of the small bowel loops with numerous air-fluid
levels and collapsed colon consistent with small bowel obstruction. The
transition point is not included on this study but was seen to be at the level
of the pelvic mass on the pelvic MRI.
2. Unchanged size of a Sister ___ nodule in the anterior abdominal
wall measuring 3.6 x 5.4 cm the last exam, but increased since ___ exam.
3. Hypo attenuating liver consistent with hepatic steatosis.
4. No new metastatic lesions are seen in the abdomen. For details regarding
the pelvis please see pelvic MRI dated ___ and for details
regarding the chest see dedicated chest CT report.
Radiology Report
EXAMINATION: CT CHEST W/CONTRAST
INDICATION: ___ female with history of leiomyosarcoma metastatic to
the lung s/p second cycle of chemotherapy. Evaluate for response to treatment.
TECHNIQUE: Contrast-enhanced chest CT was performed acquiring sequential
axial images from the thoracic inlet through the adrenal glands. Thin section
axial, coronal, sagittal and axial MIP's were also obtained. 100 cc of
Omnipaque 350 were administered intravenously without reported complication.
DOSE: As per CT abdomen/pelvis.
COMPARISON: ___.
FINDINGS:
A hypodense left thyroid lobe nodule appears slightly smaller on today's exam
measuring 5 mm, previously 8 mm (5, 4). There is no supraclavicular,
mediastinal, hilar or axillary lymphadenopathy.
Heart size is normal with no pericardial effusion. The main pulmonary artery
and thoracic aorta are normal caliber. The tip of a right pectoral MediPort
extends into the right atrium. There is no pericardial effusion. The main
pulmonary artery and thoracic aorta are normal caliber. No incidental central
pulmonary embolus is identified.
Numerous pre-existing pulmonary metastases demonstrate a mixed response to
treatment. For reference, the largest left lower lobe juxtapleural metastasis
has decreased in size measuring 2.1 x 2.5 cm, previously 2.7 x 3.4 cm (6,
152). A previously referenced lingular metastasis has also decreased in size
measuring 1.0 x 1.5 cm, previously 1.5 x 1.8 cm (6, 110). However, a right
apical subpleural metastasis is stable measuring 7 x 7 mm (6, 41). A right
apical metastasis has grown slightly larger and demonstrates increased
calcification measuring 0.8 x 1.0 cm, previously 0.6 x 0.7 cm (6, 53). A right
lower lobe metastasis has also increased in size measuring 1.2 x 1.1 cm,
previously 0.8 x 0.9 cm (6, 160). A handful of previously seen metastases have
completely resolved. Bilateral linear and subsegmental atelectasis is new
since the prior exam. There is no endobronchial lesion. A trace left pleural
effusion is new.
There are no bone lesions in the thorax worrisome for infection or malignancy.
A healing left posterolateral tenth rib fracture is again identified.
Images of the upper abdomen show new marked dilatation of multiple proximal
small bowel loops. A gastrostomy tube has been placed. For a more detailed
discussion of the upper abdomen, please refer to the separate report from the
CT abdomen/pelvis performed concurrently.
IMPRESSION:
Numerous pre-existing pulmonary metastases demonstrate a mixed response to
treatment, with some lesions demonstrating complete resolution, many lesions
showing a decrease in size, and a small minority of lesions demonstrating
interval growth.
Partially imaged upper abdomen shows new dilatation of multiple proximal small
bowel loops unclear etiology. For a more detailed discussion of the upper
abdomen, please refer to the separate report from the CT abdomen/pelvis
performed concurrently.
Healing left tenth rib fracture.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with metastatic uterine sarcoma // preop eval
preop eval
IMPRESSION:
IN COMPARISON WITH THE STUDY OF ___, THERE ARE LOWER LUNG VOLUMES BUT
OTHERWISE LITTLE CHANGE IN THE APPEARANCE OF HEART AND LUNGS. PORT-A-CATH
REMAINS IN POSITION.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with tachycardia, s/p small ___ bypass
ileocolic ___ to uterine leiomyosarcoma, got 4 liters of fluids // pulmonary
edema? pulmonary edema?
IMPRESSION:
In comparison with the study of ___, there continued low lung
volumes. There is increasing opacification at both bases, most likely
reflecting atelectatic change. In the appropriate clinical setting,
superimposed pneumonia would have to be considered.
The Port-A-Cath extends to the level of the cavoatrial junction. There is
prominent dilatation of gas-filled loops of bowel within the visualized
portion of the abdomen.
Radiology Report
EXAMINATION: BILAT LOWER EXT VEINS
INDICATION: ___ year old woman with met cancer tachycardic, // dvt?
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the bilateral lower extremity veins.
COMPARISON: None.
FINDINGS:
Left: There is normal compressibility, flow and augmentation of the left
common femoral, and popliteal veins. Compression of the superficial femoral
vein was difficult to achieve due to surrounding soft tissue edema, however
walls wall flow was demonstrated in the superficial femoral vein. Normal color
flow and compressibility are demonstrated in the posterior tibial and peroneal
veins.
Right: There is normal flow, compressibility and augmentation of the right
common femoral, superficial femoral popliteal veins. Normal color flow and
compressibility are demonstrated in the posterior tibial veins. The peroneal
veins are not well visualized.
There is normal respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
No evidence of deep venous thrombosis in the bilateral lower extremity veins.
The right peroneal veins were not visualized.
Radiology Report
EXAMINATION: CTA CHEST WANDW/O CANDRECONS, NON-CORONARY
INDICATION: Metastatic leiomyosarcoma with tachycardia. Rule out pulmonary
embolus.
TECHNIQUE: Multidetector CT through the chest performed with 100 ml of IV
contrast. Coronal and sagittal reformations were provided and reviewed.
Oblique maximum intensity projection images were created and reviewed as well.
DOSE: 254.80 mGy-cm
COMPARISON: Chest CT ___.
FINDINGS:
Contrast opacifies the segmental and subsegmental vessels of the pulmonary
arterial tree, without filling defects to indicate a pulmonary embolus. The
aorta and main pulmonary artery are normal caliber. The heart is normal size
and there is no pericardial effusion. A right-sided MediPort courses into the
right atrium.
The trachea is normal caliber. The airways are patent through the subsegmental
level. There is a new small left pleural effusion from ___.
Bibasilar atelectasis is worse from that time as well. Atelectasis in the
superior segment of the right lower lobe is unchanged. There are multiple
metastases seen throughout both lungs which are unchanged from ___. Hypoenhancement of these masses is likely related to the timing of
contrast. There is no evidence for active infection.
A 6 mm hypodensity in the left thyroid lobe is unchanged. There is no
supraclavicular, axillary or central lymphadenopathy. The esophagus is
unremarkable. Limited views of the spleen are unremarkable. Hypoattenuation of
the liver is compatible with fatty infiltration. Again, a dilated loop of
small bowel is seen in the left upper quadrant. The gastrostomy tube appears
to be well-positioned. There are no lytic or blastic osseous lesions. A
healing left tenth rib fractures again noted (5:121).
IMPRESSION:
1. No pulmonary embolus.
2. New, small left pleural effusion with an increase in bibasilar atelectasis
from 8 days prior.
3. Partially image dilated loops of small bowel, similar to prior.
4. Unchanged, intrathoracic metastatic disease.
Radiology Report
EXAMINATION: Supine and upright abdominal plain film
INDICATION: ___ with malignant SBO is setting of uterine leiomyosarcoma s/p
open small bowel bypass w/ ileocolic anastomosis // Eval SBO
COMPARISON: Comparison to prior study dated ___
FINDINGS:
Air is seen in mildly dilated loops of small bowel with multiple air fluid
levels on the upright study and a relative paucity of gas within the colon.
These findings could represent postoperative ileus although partial small
bowel obstruction should be considered. Clips in the right upper quadrant are
consistent with prior cholecystectomy. No free air is seen. Lung bases are
incompletely visualized. A gastrostomy tube projects over the expected
location of the stomach.
IMPRESSION:
Multiple loops of dilated bowel with air-fluid levels. Findings favor partial
small bowel obstruction rather than postoperative ileus given the paucity of
gas within the colon. Clinical correlation is advised and followup imaging
should be based on the clinical assessment.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Dizziness, Hypokalemia
Diagnosed with HYPOKALEMIA, ACUTE KIDNEY FAILURE, UNSPECIFIED
temperature: 97.5
heartrate: 124.0
resprate: 18.0
o2sat: 95.0
sbp: 103.0
dbp: 81.0
level of pain: 4
level of acuity: 2.0 | HOSPITAL COURSE: Ms. ___ is a ___ year old woman with uterine
leiomyosarcoma s/p surgery, adjuvant radiatoin, s/p
Gemcitabine/Docetaxol on adriamycin/ifosfamide C2D14, on TPN
(port) who was discharged on ___ after being admitted with
new abdominal masses and a small bowel obstruction secondary to
a large pelvic mass, s/p PEJ for decompression. She presented
with progressive weakness and symptomatic orthostasis, and was
found to have an acute kidney injury, severe hypokalemia (K+
2.5), and an extremely severe metabolic alkalosis (bicarb >50).
Metabolic abnormalities were considered secondary to high volume
output from her PEJ drain, and resolved with electrolyte
repletion, aggressive fluid resuscitation, and octreotide to
decrease the rate of PEJ output. After resolution of her
metabolic disturbances, it was clear that she had worsening
bowel obstruction, and restaging imaging showed enlargement of
her pelvic mass despite a second round of chemo. Pt also
triggered for SIRS and was found to have a GNR bacteremia,
treated with IV zosyn. Pt's plan for further cancer-directed
treatment was discussed at length with pt and family. She wanted
to do everything possible, and her primary oncologist Dr.
___ being able to tolerate and absorb PO intake would
be necessary before any further chemotherapy could be attempted.
As such, pt's options were discussed with the colorectal
surgical service and the pt opted to undergo surgery.
# TACHYCARDIA: Patient noted post-op to have tachycardia in
130's requiring transfer to MICU for monitoring. Thought to be
multifactorial from sepsis, hypovolemia from blood loss (had Hct
___ postop), pain. EKG did not show right-heart strain. She
received ECHO, which showed normal biventricular cavity sizes
with preserved global biventricular systolic function. LENIs
were negative for DVT. CTA was neg for PE.
# GNR BACTEREMIA: Triggered ___ AM for fever to 101.3,
tachycardia to 136, tachypnea to 32, and desaturation to 91% on
RA. CXR and CT showed atelectasis, EKG unremarkable, C. diff
negative. UA and UCx were negative for UTI. GNRs grew in blood
cx so pt started on IV zosyn to cover gut flora, for possible
bacterial translocation due to SBO. Speciation showed
Bacteroides Fragilis, beta lactamase positive with sensitivity
to_________. She was started on cefepime/flagyl.
# UTERINE SARCOMA C/B SBO: Pt presented with recurrence of small
bowel obstruction symptoms and signs on imaging, severe
metabolic derangements secondary to high volume PEJ output.
Metabolic derangements resolved with IVF/electrolyte repletion,
and PEJ output slowed down after starting octreotide. Re-staging
by imaging showed interval progression of pelvic despite second
round of adriamycin/ifosfamide; however, pulmonary nodules had
decreased in size and no other metastatic disease was found in
the abdomen. Dr. ___ care, and OMED team met
with pt and family to discuss re-planning of future
cancer-directed and palliative therapy. Colorectal agreed to do
palliative surgery to help with obstructive issue in order to
allow pt to attempt further chemo. Colorectal took pt to the OR
on ___ and performed an exploratory laparotomy, excision of
subcutaneous metastases and ileocolic bypass.
# HYPOKALEMIA: Low serum K on admission to 2.3. Likely due to
high serum pH pushing K into cells, as well as urine loss of K
(K<100 in urine lytes) due to high delivery of bicarb to distal
tubules. Other contributing factors include low PO intake of K,
and effect of iphosphamide causing urine wasting of K. Pt likely
had high total body K from TPN, which began to manifest once
serum pH was lowered. K was repleted per nephrology recs, and pt
demonstrated hyperkalemia after serum bicarb began to fall,
after which K repletion was held and no further repletion was
necessary. Pt was kept on telemetry without incident. TPN
formula was adjusted.
# METABOLIC ALKALOSIS: Very severe, w/ bicarb above assay on ___
(>50). Most likely due to excessive GI acid losses via PEJ tube.
Excess bicarb delivery to distal tubule also likely contributing
factor to hypokalemia and high urine potassium (>100). High
serum pH also contributed to low serum potassium despite
potentially high total body K as pH is pushing K into cells (see
above). Volume depletion also a likely contributing factor
secondary to contraction alkalosis. Bicarb dropped to normal
range after aggressive volume resuscitation with NS. Pt then
appeared mildly volume overloaded on exam, due to slowing of PEJ
output and volume repletion, and was given a small dose of IV
lasix, after which her peripheral edema improved.
# ___: Likely pre-renal component as pt had poor PO intake in
the week leading up to admission, high output from PEJ, and some
contribution from anemia (see below). Cr dropped back down to
baseline at 0.6 after aggressive volume repletion, indicating
likely hypovolemia.
# ANEMIA: Slowly downtrending Hct/Hgb, accelerated by dilution
after receiving a lot of IVF. Hct very low at 19.8 on ___.
Showed an appropriate bump to 25.7 on ___ after 1U PRBC
transfusion. Iron panel and hemolysis labs show iron deficiency
anemia secondary to inflammation/chronic disease. Was
transferred to MICU after Hct drop from 29.8->19.9 and received
3 units pRBC with significant increase to 32.6 on ___.
Colorectal Surgery Brief Hospital Course
Mrs. ___ is a ___ year woman who was transferred to colorectal
surgery from the oncology service for treatment of her bowel
obstruction. On ___, post-operatively, she was noted to be
tachycardic to 140-150s and her Hct was down from 29.8 to 19.8
she was mainaged in the ICU. She had recieved blood prior to her
surgery. On ___ her hematocrit was stable and she was
started on cefepime/flagyl. she was again noted to be
tachicardic to 140 with a Tmax of 100.5. She was monitored
closely and cared for appropriately. On ___ the G-tube was
clamped and unfortunately she had emesis. Because of the
continued tachycardia, a CTA chest was obtained to rule out PE
which was negative. She was improved and was transfered to 5
___. On ___ she complained of increased pain which was
treated appropriately and the foley catheter was removed. On
___ a KUB showed improved small bowel obstruction. She
remianed stable, her bowel function was montiored closely. On
___ she had emesis of 400cc, and had some sinus
tachycardia. On ___ she had frequent bowel movements, the
Gtube was capped and her electrolytes were repleated
appropriately. She continued on antibiotics. On ___ her
Blood cultures were final and negative and the antibiotics were
discontinued. Throughout this time, TPN was continued. She was
looking well and advancing her diet. She was in good spirits. On
___ she was much improved and approaching discharge howere,
her portacath was without blood return and TPA was instilled,
this was a long process and required her to stay in the hospital
with a reeval of the por on ___. On ___ the port was
flushing and she was able to be discharged home with appropriate
followup. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
prednisone
Attending: ___
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ woman with hx of CF (was just officially diagnosed in ___,
has a rare gene mutation) presents with epigastric pain, nausea,
vomiting (up to 10x), diarrhea since last night, similar to
previous admissions for pancreatitis. She called her
gastroenterologist, Dr. ___ instructed her to go to
the
ED. She describes her epigastric pain as nonstop and sharp. She
was last admitted here in ___ for pancreatitis. Reports
decreased appetite; has not eaten since ___ dinner (fajitas).
She reports she has had three episodes of bronchitis recently
___, ___. For these episodes she went to see Dr. ___ at
___ who is her CF doctor.
In the ED, initial VS were 97.3 66 14 146/91 100 RA
Exam was notable for severe epigastric and LUQ tenderness,
abdominal distension.
Labs showed WBC 5.4, Hb 10.2, Hct 30.9, Plt 406, Na 141, K
5.9(hemolyzed), Cl 102, HCO3 25, BUN 6, Cr 0.5, Gl 91, Lactate
1.6, AST 65, Lip 35
Imaging:
___: CXR showed no evidence of pneumonia. No intraperitoneal
free air.
Received in ED:
2L NS, morphine 4mg x4, and Zofran 4mg x1
Transfer VS were:
___ 100/66 15 98% RA
On arrival to the floor, patient reports she has a headache and
thinks it was from the morphine. She reports that her pain is
currently a 7 and was at worst an 8.
REVIEW OF SYSTEMS:
(+)PER HPI: Positive for nausea, vomiting, diarrhea
also positive for headache since ED
Denies chest pain or SOB.
Past Medical History:
Chronic pancreatitis relating to CF gene mutation
arthritis s/p L and R TKR
Cervical CA s/p TAHBSO
Depression
GERD
L shoulder arthroplasty (___)
L shoulder surgery (___)
Nephrolithiasis
Social History:
___
Family History:
maternal grandmother: diabetes, "heart problems"
2 brothers - have not been tested yet
1 daughter - has not been tested
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
VS: 2219 97.5 PO 126 / 58 L Lying 60 18 97 Ra
GENERAL: In obvious distress and pain, lying supine in bed.
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
NECK: supple, no LAD, no JVD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: Tattoo on abdomen. Extremely tender to palpation in the
epigastric area, non tender elsewhere. Diminished bowel sounds.
EXTREMITIES: no cyanosis, clubbing. 1+ pretibial pitting edema.
DISCHARGE PHYSICAL EXAM
=======================
VS: 98.2 148/73 58 18 96 Ra
GENERAL: Comfortable lying supine in bed.
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
NECK: supple, no LAD, no JVD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: Tattoo on abdomen. Mildly TTP in epigastric area, non
tender elsewhere. Diminished bowel sounds. EXTREMITIES: no
cyanosis, clubbing. 1+ pretibial pitting edema.
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
ADMISSION LABS
==============
___ 12:36PM BLOOD WBC-5.4 RBC-3.44* Hgb-10.2* Hct-30.9*
MCV-90 MCH-29.7 MCHC-33.0 RDW-13.7 RDWSD-44.9 Plt ___
___ 12:36PM BLOOD Neuts-50.5 ___ Monos-8.7 Eos-3.5
Baso-0.6 Im ___ AbsNeut-2.75 AbsLymp-1.98 AbsMono-0.47
AbsEos-0.19 AbsBaso-0.03
___ 12:36PM BLOOD ___ PTT-29.1 ___
___ 12:36PM BLOOD Glucose-91 UreaN-6 Creat-0.5 Na-141
K-5.9* Cl-102 HCO3-25 AnGap-14
___ 12:36PM BLOOD ALT-30 AST-65* AlkPhos-68 TotBili-<0.2
___ 12:36PM BLOOD Albumin-3.6 Calcium-9.2 Phos-4.5 Mg-1.7
DISCHARGE LABS
==============
___ 06:45AM BLOOD WBC-5.1 RBC-3.60* Hgb-11.0* Hct-32.6*
MCV-91 MCH-30.6 MCHC-33.7 RDW-13.3 RDWSD-44.4 Plt ___
___ 06:45AM BLOOD Glucose-88 UreaN-9 Creat-0.6 Na-142 K-4.2
Cl-103 HCO3-23 AnGap-16
___ 06:45AM BLOOD Calcium-9.7 Phos-5.2* Mg-1.6
MICRO
=====
___ 4:25 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
IMAGING
=======
___ Chest Xray
IMPRESSION:
No evidence of pneumonia. No evidence of free air.
___ KUB
IMPRESSION:
No radiographic evidence of obstruction. Moderate fecal
retention.
___ Lower Extremity Ultrasound
IMPRESSION:
No evidence of deep venous thrombosis in the right or left lower
extremity
veins.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Diphenoxylate-Atropine 2 TAB PO Q6H:PRN diarrhea
2. Escitalopram Oxalate 20 mg PO DAILY
3. Gabapentin 600 mg PO TID
4. Omeprazole 20 mg PO DAILY
5. OxyCODONE (Immediate Release) 10 mg PO Q6H:PRN Pain -
Moderate
6. Viokace (lipase-protease-amylase) 10,440-39,150- 39,150 unit
oral TID W/MEALS
7. Atorvastatin 10 mg PO QPM
8. Amitriptyline 25 mg PO QHS:PRN insomnia
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*30 Capsule Refills:*0
2. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 [Miralax] 17 gram/dose 1 powder(s)
by mouth daily Refills:*0
3. Senna 8.6 mg PO BID
RX *sennosides [senna] 8.8 mg/5 mL 1 by mouth twice a day
Refills:*0
4. Amitriptyline 25 mg PO QHS:PRN insomnia
5. Atorvastatin 10 mg PO QPM
6. Escitalopram Oxalate 20 mg PO DAILY
7. Gabapentin 600 mg PO TID
8. Omeprazole 20 mg PO DAILY
9. OxyCODONE (Immediate Release) 10 mg PO Q6H:PRN Pain -
Moderate
10. Viokace (lipase-protease-amylase) 10,440-39,150- 39,150
unit oral TID W/MEALS
11. HELD- Diphenoxylate-Atropine 2 TAB PO Q6H:PRN diarrhea This
medication was held. Do not restart Diphenoxylate-Atropine until
you see your PCP. this can cause constipation
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis
=================
Abdominal Pain
Constipation
Secondary Diagnosis
===================
GERD
Hyperlipidemia
Depression
Chronic Abdominal Pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION:
Chest: Frontal and lateral views
INDICATION: History: ___ with upper abd pain// concern for GI perf vs PNA
TECHNIQUE: Chest: Upright AP frontal and Lateral
COMPARISON: Chest radiograph ___.
FINDINGS:
Patient is status post left shoulder hemiarthroplasty.The lungs are clear
without focal consolidation. No pleural effusion or pneumothorax is seen. The
cardiac and mediastinal silhouettes are unremarkable. There is no
intraperitoneal free air.
IMPRESSION:
No evidence of pneumonia. No evidence of free air.
Radiology Report
INDICATION: ___ year old woman with acute on chronic pancreatitis and
abdominal distention. Look for obstruction
TECHNIQUE: Supine and upright abdominal radiographs were obtained.
COMPARISON: CT abdomen pelvis from ___
FINDINGS:
Lung bases are clear. Mediastinal silhouette is within normal limits. There
are no abnormally dilated loops of large or small bowel. Moderate amount of
stool seen throughout the colon.
There is no free intraperitoneal air.
Osseous structures are notable for mild scoliosis at L2-L3.
There are no unexplained soft tissue calcifications or radiopaque foreign
bodies.
IMPRESSION:
No radiographic evidence of obstruction. Moderate fecal retention.
Radiology Report
EXAMINATION: ___ DUP EXTEXT BIL (MAP/DVT)
INDICATION: ___ year old woman with pancreatitis in for management of possible
acute pancreatitis.// DVT?
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the bilateral lower extremity veins.
COMPARISON: None.
FINDINGS:
There is normal compressibility, flow, and augmentation of the bilateral
common femoral, femoral, and popliteal veins. Normal color flow and
compressibility are demonstrated in the posterior tibial and peroneal veins.
There is normal respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
No evidence of deep venous thrombosis in the right or left lower extremity
veins.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Abd pain
Diagnosed with Other chronic pancreatitis
temperature: 97.3
heartrate: 66.0
resprate: 14.0
o2sat: 100.0
sbp: 146.0
dbp: 91.0
level of pain: 8
level of acuity: 3.0 | BRIEF HOSPITAL COURSE
=====================
___ with past medical history of chronic pancreatitis secondary
to Cystic Fibrosis and recurrent flares of chronic pancreatitis
episodes, cervical CA s/p TAH/BSO, asthma and depression, who
presented with severe epigastric abdominal pain. Patient had
labs showing normal LFTs and lipase and a KUB showing large
stool burden. Likely pain was secondary to constipation vs a
flare or her chronic pancreatitis. The abdominal pain greatly
improved with a bowel regimen. Patient was discharged on a bowel
regimen and advised to follow-it while taking her Oxycodone
medication.
======================= |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Codeine / Augmentin / heparin
/ ciprofloxacin / gabapentin
Attending: ___
Chief Complaint:
Urinary tract infection
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
Ms. ___ is a ___ w/ h/o DM1 c/b retinopathy, nephropathy,
neuropathy, gastroparesis, CAD s/p CABG with bioprosthetic MVR,
HFpEF, recurrent diabetic foot ulcers with recent below the knee
amputation of left leg presenting for incontinence and
suprapubic fullness.
Patient had UTI 2 weeks ago that was treated by her outpatient
nephrologist. She completed treatment with gentamycin last week.
She reports having suprapubic fullness and incontinence today
while trying to get to a commode. She denies any dysuria or
hematuria. The suprapubic pressure has been occuring since her
last UTI and has persisted even after treatment.
She denies any assocaited fevers, chill, nausea, vomiting,
diarrhea, chest pain, abdominal pain or shortness of breath.
In the ED, initial vitals: 8 98.5 73 141/74 18 98% RA
Labs notable for: WBC 13.0, Hgb/Hct 12.3/36.7, BUN/Cr 45/3.9,
U/A with large leuks, negative nitrites, many bacteria.
Patient was given her home medications and 500mg of IV meropenum
Vitals prior to transfer: 98.4 65 ___ 18 97% Nasal Cannula
REVIEW OF SYSTEMS(+) As per HPI
(-) fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, abdominal pain, nausea, vomiting, diarrhea,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
Past Medical History:
- ___
___ TTE: Well seated bioprosthetic mitral prosthesis high
normal gradient. Mild symmetric LVH. LVEF >55%
- Mild PAH
- ESRD: tunneled HD line ___
- CAD s/p CABG/bio MVR ___
- Afib (following CABG) on coumadin
- DM1 (complicated by retinopathy, nephropathy, neuropathy,
gastroparesis)
- Diabetic foot ulcers, PVD: non-healing L heel ulcer s/p angio
___ followed by ___
- CAD s/p CABG and MVR ___
- Charcot foot
- HLD
- HTN
- Mitral regurgitation s/p bioprosthetic MVR ___
- Endometriosis
- Blind in R eye
- Orthostatic hypotension secondary to autonomic neuropathy
Recent admissions:
___ (C diff, ___
___ (___)
___ (foot ulcer, UTI, dCHF)
___ (___ - CMED)
___ (foot ulcer - VSurg)
___ (___)
___ (CHF)
___ (___)
___ (___)
___ (pyelonephritis)
___ (Hyperglycemia)
___ (Left below the knee amputation)
PAST SURGICAL HISTORY
- CABG w/MVR (___)
- Laproscopic procedures for endometriosis
- Tonsillectomy
- Multiple eye surgeries
- Multiple B/L foot debridements (with podiatry)
- Amputation of Left leg below the knee
Social History:
___
Family History:
Mother: HTN, ___
Father: ___, CVA, CAD, MI
No history of malignancy
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 98.1 69 104/43 18 100%RA
General: AAOx3, NAD
HEENT: enuculeated R eye, conjunctiva pink, sclera anicteric,
MMM
CV: RRR, ___ SEM heard best at ___
Pulm: CTAB, no wheezes, rhonchi or rales
Abd:soft, +BS, non-distended, suprapubic tenderness to
palpation
Thorax: R HD line, erythema present around site, non tender to
palpation
RLE: trace edema, mild ttp
LLE: tender to palpation around right knee (patient states its
been tender since amputation) no erythema, amputation below the
knee
DISCHARGE PHYSICAL EXAM:
Vitals: 98.1 68 154/52 18 98 % RA
General: AAOx3, NAD
HEENT: enuculeated R eye, conjunctiva pink, sclera anicteric,
MMM
CV: RRR, ___ SEM heard best at LUSB
Pulm: CTAB, no wheezes, rhonchi or rales
Abd:soft, +BS, non-distended, suprapubic tenderness to
palpation
Thorax: R HD line, erythema present around site, non tender to
palpation
RLE: trace edema, mild ttp
LLE: Amputation below the knee
Pertinent Results:
Admission Labs
___ 04:50AM BLOOD WBC-13.0*# RBC-3.96*# Hgb-12.3# Hct-36.7#
MCV-93 MCH-31.0 MCHC-33.4 RDW-15.6* Plt ___
___ 04:50AM BLOOD Neuts-86.8* Lymphs-6.2* Monos-4.6 Eos-2.1
Baso-0.2
___ 04:50AM BLOOD Glucose-336* UreaN-45* Creat-3.9*#
Na-130* K-5.2* Cl-92* HCO3-25 AnGap-18
___ 04:50AM BLOOD Calcium-9.2 Phos-5.2*# Mg-2.4
___ 07:22AM BLOOD K-4.8
___ 04:30AM URINE Color-Yellow Appear-Cloudy Sp ___
___ 04:30AM URINE Blood-SM Nitrite-NEG Protein-300
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-LG
___ 04:30AM URINE RBC-30* WBC->182* Bacteri-MANY Yeast-NONE
Epi-0
___ 04:30AM URINE WBC Clm-MOD
Discharge Labs
___ 10:17AM BLOOD WBC-9.6 RBC-3.89* Hgb-11.6* Hct-35.1*
MCV-90 MCH-29.8 MCHC-33.0 RDW-15.4 Plt ___
___ 10:17AM BLOOD Glucose-308* UreaN-39* Creat-2.5* Na-133
K-4.5 Cl-94* HCO3-28 AnGap-16
___ 10:17AM BLOOD Calcium-8.9 Phos-4.6* Mg-2.3
MICRO
Date/Time: ___ 6:53 am
URINE ADDED TO GRAY HOLD ___.
URINE CULTURE (Preliminary):
Fosfomycin REQUESTED BY ___. ___ (___) ___..
KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMIKACIN-------------- <=2 S
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- 32 R
CEFTAZIDIME----------- =>64 R
CEFTRIAXONE----------- 4 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 256 R
PIPERACILLIN/TAZO----- 16 S
TOBRAMYCIN------------ 8 I
TRIMETHOPRIM/SULFA---- <=1 S
IMAGING
___ 9:15 AM# ___ RENAL U.S.
1. Multiple small, bilateral, nonobstructive renal calculi. No
hydronephrosis.
2. Distended urinary bladder with layering sediment and mild
smooth wall
thickening.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lactulose 30 mL PO DAILY
2. Acetaminophen 1000 mg PO Q8H
3. Lisinopril 10 mg PO DAILY
4. Gabapentin 100 mg PO TID
5. Lidocaine 5% Patch 1 PTCH TD QAM
6. Metoprolol Succinate XL 50 mg PO DAILY
7. Docusate Sodium 100 mg PO BID Constipation
8. Senna 8.6 mg PO BID:PRN constipation
9. Apixaban 5 mg PO BID
10. Epoetin Alfa 4000 units SC 3 TIMES A WEEK
11. Atorvastatin 80 mg PO QPM
12. Ferrous Sulfate 100 mg PO 1X/WEEK (___)
13. Fentanyl Patch 50 mcg/h TD Q72H
14. HYDROmorphone (Dilaudid) ___ mg PO BID:PRN pain
15. TraMADOL (Ultram) 50 mg PO BID
16. sevelamer CARBONATE 800 mg PO TID W/MEALS
17. Omeprazole 40 mg PO DAILY
18. Aspirin 81 mg PO DAILY
19. Cetirizine 10 mg PO DAILY
20. Levothyroxine Sodium 25 mcg PO DAILY
21. Cyanocobalamin 500 mcg PO DAILY
22. Nephrocaps 1 CAP PO DAILY
23. NPH 32 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Apixaban 5 mg PO BID
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 80 mg PO QPM
5. Cetirizine 10 mg PO DAILY
6. Cyanocobalamin 500 mcg PO DAILY
7. Docusate Sodium 100 mg PO BID Constipation
8. Fentanyl Patch 50 mcg/h TD Q72H
9. Gabapentin 100 mg PO DAILY
10. HYDROmorphone (Dilaudid) ___ mg PO BID:PRN pain
11. NPH 32 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
12. Lactulose 30 mL PO DAILY
13. Levothyroxine Sodium 25 mcg PO DAILY
14. Lidocaine 5% Patch 1 PTCH TD QAM
15. Lisinopril 10 mg PO DAILY
16. Nephrocaps 1 CAP PO DAILY
17. Omeprazole 40 mg PO DAILY
18. Senna 8.6 mg PO BID:PRN constipation
19. sevelamer CARBONATE 800 mg PO TID W/MEALS
20. TraMADOL (Ultram) 50 mg PO BID
21. Epoetin Alfa 4000 units SC 3 TIMES A WEEK
22. Ferrous Sulfate 100 mg PO 1X/WEEK (___)
23. Metoprolol Succinate XL 50 mg PO DAILY
24. Meropenem 1000 mg IV POST HD (___)
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
URINARY TRACT INFECTION
END STAGE RENAL DISEASE
SECONDARY DIAGNOSIS
TYPE 1 DIABETES MELLITUS
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
EXAMINATION: RENAL U.S.
INDICATION: ___ w/ h/o DM1 c/b retinopathy, nephropathy, neuropathy,
gastroparesis, CAD s/p CABG with bioprosthetic MVR, HFpEF, recurrent diabetic
foot ulcers with recent below the knee amputation of left leg presenting for
incontinence, suprapubic fullness, leukocytosis and UA concerning for UTI. //
rule out perinephric abscess
TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were
obtained.
COMPARISON: Renal ultrasound dated ___.
FINDINGS:
The right kidney measures 9.5 cm. The left kidney measures 9.6 cm. Multiple
small, nonobstructive calculi are noted within the upper and lower poles of
the bilateral kidneys. There is no hydronephrosis or masses bilaterally.
Normal cortical echogenicity and corticomedullary differentiation are seen
bilaterally.
The bladder is well distended, measuring approximately 350-400 cc in pre-void
volume. There is a small amount of layering debris, and mild smooth urinary
bladder wall thickening which is similar to the prior examination.
IMPRESSION:
1. Multiple small, bilateral, nonobstructive renal calculi. No
hydronephrosis.
2. Distended urinary bladder with layering sediment and mild smooth wall
thickening.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Dysuria
Diagnosed with URIN TRACT INFECTION NOS, PRESSURE ULCER, LOWER BACK, PRESSURE ULCER, UPPER BACK, PRESSURE ULCER, UNSPECIFIED STAGE
temperature: 98.5
heartrate: 73.0
resprate: 18.0
o2sat: 98.0
sbp: 141.0
dbp: 74.0
level of pain: 8
level of acuity: 3.0 | ___ DM1 c/b retinopathy, nephropathy, neuropathy,
gastroparesis, CAD s/p CABG with bioprosthetic MVR, HFpEF,
recurrent diabetic foot ulcers with recent below the knee
amputation of left leg presenting for incontinence, suprapubic
fullness, leukocytosis, found to have Klebsiella UTI.
#UTI: Patient presented with suprapubic fullness, urinary
incontinence and leukocytosis. UA was concerning for infection.
Patient has history of resistant organisms including Klebsiella,
Pseudomonas and Enterococcus. She was treated empirically with
meropenem, should be continued on 14-day course for complicated
UTI. Renal ultrasound showed no evidence of abscess. Per
nephrology consult, patient is unable to have PICC access, so
meropenem was dosed to be given after HD sessions after
discussion with infectious disease pharmacist. Patient was found
to retain urine and was restarted on straight catheterizations
by ___. She will receive meropenem with hemodialysis for 14-day
course for complicated UTI with last dose to be administered
___. Unfortunately, patient decided to leave before
discharge planning could be completed to ensure patient would
receive her antibiotics at HD. Fosfomycin sensitivity was sent
and pending at discharge, and her dialysis center was not
certain they would have meropenem available by her next dose on
___ (but would have it available by ___. Patient requested
discharge regardless, stating she would follow up with PCP on
___ to follow up on fosfomycin sensitivity. If she is unable
to receive meropenem at HD on ___, she will request infusion
at ___ on ___ or states she would present to
the ED. Unfortunately, unable to confirm pheresis unit would
have meropenem available at time of discharge (closed at the
time they were called).
# Hyponatremia: Patient with baseline hyponatremia in 130s
likely secondary to hypervolemic hyponatremia
- 1L fluid restriction per nephrology
# Diabetes Mellitus Type I: Patient with long standing history
complicated by retinopathy, neuropathy, nephropathy and
gastroparesis. Has had admissions for hyper- and hypo- glycemia.
She was continued on home insulin regimen- 32 ___ qAM with
SSI.
# Decubitis sacral pressure ulcer- patient was evalauted by
wound care nursing and recommended petroleum base skin ointment. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
lisinopril / latex
Attending: ___.
Chief Complaint:
abdominal pain and fever
Major Surgical or Invasive Procedure:
Left percutaneous nephrostomy tube ___
History of Present Illness:
___ female with history of HTN, DM, biopolar disease,
nephrolithiasis with prior placement of ureteral stents and
lithotripsy, anatomic urologic anomalies, who presented to the
ED w/ abd pain, hypotension, and fever.
Per report, patient presented from assisted living facility with
fever/chills, abdominal pain, and hypotension (SBPs in ___. Her
symptoms reportedly started on ___. She also had
accompanying decreased UOP, N/V, and CP/SOB. Per group home
director, patient takes daily macrobid for UTI prophylaxis. On
arrival per EMS, patient lethargic but SBPs ___.
Of note, patient has history of MDR UTI. She has a duplicated
bilateral renal collecting system with joining of the systems at
the left UPJ and mild chronic left sided hydronephrosis. She
takes daily Macrobid as suppressive therapy. Her last UTI in
___ and ___ was E. Coli, resistant to ceftaz, ceftriaxone
and cipro but sensitive to Zosyn. In ___ she had a MRSA UTI.
In ___ she had a pan-sensitive pseudomonas UTI.
ED Course notable for:
Initial vitals: 102.1 91 96/47 18 97% RA
Receieved IV fluids as well as Zosyn/Vanc. She was found to have
a significant leukocytosis and rising Cr, with a UA significant
for large Leuk, >182 WBCs, and moderate bacteria. CXR concerning
for LLL pneumonia and pleural effusion, renal U/S w/ left
hydronephrosis secondary to an obstructing 6 mm left proximal
ureteral stone. CT abd showed moderate hydroureteronephrosis of
both the superior and inferior moiety secondary to an
obstructing punctate calculus at the left ureterovesicular
junction. Urology was consulted in the ED, recommended emergent
___ Left PCN for decompression.
Patient initially refused procedure, but after discussion with
HCP. she was intubated and taken down for the procedure. Per ___
sign out the procedure was successful and L PCN was placed.
Patient required levophed given peripherally during procedure.
A-line was placed for blood pressure monitoring.
Patient was extubated in the PACU and is maintaining O2 sats on
nasal cannula. Prior to transfer SBP 160s
On arrival to the MICU, patient reports she would like to go
back to her room. She wants spaghetti for dinner. She is not
having any abdominal pain or flank pain. She has pain in her L
leg, which she reports is chronic in nature. She denies fevers,
chills, shortness of breath.
Past Medical History:
PAST MEDICAL & SURGICAL HISTORY:
Fetal alcohol syndrome
Schizophrenia
Diabetes mellitus type 2, non-insulin dependent
Asthma
Hypertension
Hypothyroidism
Hyperparathyroidism with hx nephrolithiasis s/p b/l stent
placement, s/p Parathyroidectomy with Re-implantation & Partial
thyroidectomy
Fecal Incontinence
Urinary Incontinence
Past Surgical Hx: Mastoidectomy/tympanoplasty, left percutaneous
nephrolithotomy, left laser lithotripsy, bilateral ureteral
stents
Social History:
___
Family History:
No significant family history of UTI / sepsis.
Physical Exam:
Admission physical exam
======================
VITALS: Reviewed in metavision
GENERAL: Alert, oriented to person, tremulous
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: Crackles in L lung base
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, L PCN in place over L flank.
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. No swelling of LLE, L knee without notable effusion
Discharge physical exam
===========================
VITALS: ___ 1144 Temp: 98.7 BP: 161/102 L Lying HR: 79 RR:
18 O2 sat: 94% O2 delivery: RA FSBG: 257
GENERAL: NAD, sitting up in bed, bright, alert and awake
EYES: Anicteric, PERRL
ENT: MMM. poor dentition
CV: Heart regular, no m/g. JVP 6cm
RESP: Lungs CTAB no w/r/r. Breathing comfortably
GI: Abdomen soft, NTND. Bowel sounds present.
GU: No suprapubic ttp or fullness; L nephrostomy site clean w/
red (fruit punch) colored urine without clots
MSK: Extremities warm without edema. Moves all extremities
SKIN: No rashes or ulcerations noted on examined skin
NEURO: follows simple commands, moves all extremities, unable to
assess orientation as she does not answer questions
PSYCH: calm
Pertinent Results:
Admission labs
=================
___ 12:30AM BLOOD WBC-24.9* RBC-3.60* Hgb-11.2 Hct-34.9
MCV-97 MCH-31.1 MCHC-32.1 RDW-15.8* RDWSD-56.2* Plt ___
___ 12:30AM BLOOD Neuts-77.9* Lymphs-7.1* Monos-12.1
Eos-0.0* Baso-0.1 Im ___ AbsNeut-19.42* AbsLymp-1.76
AbsMono-3.01* AbsEos-0.00* AbsBaso-0.02
___ 12:30AM BLOOD ___ PTT-26.1 ___
___ 12:30AM BLOOD Glucose-144* UreaN-51* Creat-2.7*# Na-139
K-5.3 Cl-101 HCO3-22 AnGap-16
___ 12:30AM BLOOD ALT-17 AST-16 AlkPhos-91 TotBili-0.3
___ 08:45AM BLOOD Calcium-8.2* Phos-5.0* Mg-1.8
___ 01:18PM BLOOD Type-ART PEEP-5 FiO2-40 pO2-135* pCO2-27*
pH-7.45 calTCO2-19* Base XS--2 Intubat-INTUBATED Vent-CONTROLLED
Discharge labs
===============
___ 06:20AM BLOOD WBC-11.6* RBC-3.05* Hgb-9.2* Hct-29.3*
MCV-96 MCH-30.2 MCHC-31.4* RDW-16.5* RDWSD-57.5* Plt ___
___ 06:20AM BLOOD Glucose-121* UreaN-35* Creat-1.5* Na-147
K-4.8 Cl-110* HCO3-24 AnGap-13
___ 06:20AM BLOOD Calcium-8.8 Phos-3.5 Mg-1.7
Microbiology
=============
Blood Culture, Routine (Pending): No growth to date.
___ 5:58 am BLOOD CULTURE Source: Venipuncture.
Blood Culture, Routine (Pending): No growth to date.
___ 8:07 pm URINE Source: Catheter.
**FINAL REPORT ___
Legionella Urinary Antigen (Final ___:
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
(Reference Range-Negative).
Performed by Immunochromogenic assay.
A negative result does not rule out infection due to other
L. pneumophila serogroups or other Legionella species.
Furthermore, in infected patients the excretion of antigen
in urine may vary.
___ 2:10 pm URINE,KIDNEY Source: Kidney.
FLUID CULTURE (Preliminary):
ESCHERICHIA COLI. > 10,000 CFU/ML.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 8 S
CEFAZOLIN------------- =>64 R
CEFTAZIDIME----------- 16 R
CEFTRIAXONE----------- =>64 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- =>512 R
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED.
___ 12:15 am BLOOD CULTURE Site: ARM
Blood Culture, Routine (Pending): No growth to date.
___ 12:30 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
STAPHYLOCOCCUS, COAGULASE NEGATIVE.
Isolated from only one set in the previous five days.
SENSITIVITIES PERFORMED ON REQUEST..
Aerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN CLUSTERS.
Reported to and read back by ___ X ___
___ 23:20.
Anaerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN CLUSTERS.
Reported to and read back by ___ ___ ___
23:20.
___ 12:30 am URINE Site: CATHETER
**FINAL REPORT ___
URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 CFU/mL.
PRESUMPTIVE IDENTIFICATION.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- =>64 R
CEFTAZIDIME----------- 16 R
CEFTRIAXONE----------- =>64 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- =>512 R
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ 2 S
TRIMETHOPRIM/SULFA---- =>16 R
IMAGING
============
CTU (Abd/Pel) without contrast (___)
IMPRESSION:
1. Duplex left renal collecting system with moderate
hydronephrosis of both the superior and inferior pole moieties.
Both moieties have a common ureter which is obstructed by a
punctate calculus lodged at the left ureterovesical junction.
The entire left kidney is enlarged with extensive stranding of
perinephric fat and locules of air within the left renal lower
pole collecting systems concerning for underlying infection.
There are multiple non-obstructing left renal moiety lower pole
calculi.
2. Imaging findings of chronic pancreatitis remain unchanged
dating back to ___.
3. Stable 1.8 cm incompletely characterized right adrenal nodule
is unchanged dating back ___.
Chest CT W/O contrast (___)
IMPRESSION:
1. Mild narrowing of the mid trachea.
2. Substantial left lower lobe atelectasis with mucus plugging.
Lesser right
lower lobe atelectasis.
3. Very small pleural effusions.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Docusate Sodium 100 mg PO QHS
2. Nitrofurantoin (Macrodantin) 100 mg PO QHS
3. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
4. GuaiFENesin 5 mL PO Q6H:PRN cough
5. Carvedilol 12.5 mg PO BID
6. Aspirin 81 mg PO DAILY
7. Atorvastatin 20 mg PO QPM
8. Levothyroxine Sodium 137 mcg PO DAILY
9. Vitamin D 1000 UNIT PO DAILY
10. ClonazePAM 0.5 mg PO DAILY
11. Levemir 8 Units Breakfast
12. Spironolactone 25 mg PO DAILY
13. SITagliptin 50 mg oral DAILY
14. BuPROPion (Sustained Release) 100 mg PO QAM
15. Divalproex (DELayed Release) 500 mg PO BID
16. Ditropan XL (oxybutynin chloride) 10 mg oral DAILY
17. Systane (PF) (peg 400-propylene glycol (PF)) 0.4-0.3 %
ophthalmic (eye) QID
18. GlipiZIDE XL 5 mg PO DAILY
19. QUEtiapine Fumarate 300 mg PO BID
Discharge Medications:
1. Artificial Tears ___ DROP BOTH EYES BID:PRN dry eyes
2. Heparin Flush (10 units/ml) 2 mL IV DAILY and PRN, line
flush
3. Piperacillin-Tazobactam 2.25 g IV Q6H
Last dose ___. Sodium Chloride 0.9% Flush 10 mL IV DAILY and PRN, line
flush
5. Glargine 6 Units Breakfast
Insulin SC Sliding Scale using Novalog Insulin
6. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
7. Aspirin 81 mg PO DAILY
8. Atorvastatin 20 mg PO QPM
9. BuPROPion (Sustained Release) 100 mg PO QAM
10. Carvedilol 12.5 mg PO BID
11. ClonazePAM 0.5 mg PO DAILY
12. Ditropan XL (oxybutynin chloride) 10 mg oral DAILY
13. Divalproex (DELayed Release) 500 mg PO BID
14. Docusate Sodium 100 mg PO QHS
15. GlipiZIDE XL 5 mg PO DAILY
16. GuaiFENesin 5 mL PO Q6H:PRN cough
17. Levothyroxine Sodium 137 mcg PO DAILY
18. QUEtiapine Fumarate 300 mg PO BID
19. SITagliptin 50 mg oral DAILY
20. Systane (PF) (peg 400-propylene glycol (PF)) 0.4-0.3 %
ophthalmic (eye) QID
21. Vitamin D 1000 UNIT PO DAILY
22. HELD- Nitrofurantoin (Macrodantin) 100 mg PO QHS This
medication was held. Do not restart Nitrofurantoin (Macrodantin)
until finish course of Zosyn on ___, then may be resumed
23. HELD- Spironolactone 25 mg PO DAILY This medication was
held. Do not restart Spironolactone until sees PCP
___:
Extended Care
Facility:
___
Discharge Diagnosis:
Sepsis from urinary tract infection
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
INDICATION: History: ___ with CP SOB fevers// ?PNA
TECHNIQUE: Portable frontal chest radiograph.
COMPARISON: ___ chest radiograph.
FINDINGS:
Lung volumes are low. In the left lower lobe is an opacity obscuring the
heart apex and left hemidiaphragm with air bronchograms, likely reflecting
left lower lobe pneumonia. Prominence of the bilateral central pulmonary
vasculature suggest mild interstitial pulmonary edema. There is likely also a
small left pleural effusion. No evidence of pneumothorax.
IMPRESSION:
1. Dense opacity in the left lower lung field suggests left lower lobe
pneumonia/atelectasis.
2. Mild bilateral pulmonary vascular congestion.
3. Left pleural effusion.
Radiology Report
EXAMINATION: RENAL U.S.
INDICATION: History: ___ with history of HTN, bipolar disorder, here with
abdominal pain and likely UTI septic from this on this presentation// please
evaluate for hydro ___ nephric stranding
TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were
obtained.
COMPARISON: None.
FINDINGS:
Right kidney: 9.6 cm. Re-demonstrated in the mid to lower pole of the right
kidney is an anechoic 2.7 x 2.5 x 2.9 cm simple cyst.
Left kidney: 15.4 cm. Multiple stones are re-demonstrated within the left
kidney, measuring up to 1.3 cm in the left lower pole. There is moderate
left-sided hydronephrosis and proximal hydroureter. A 6 mm nonobstructing
calculus is noted within the dilated left renal pelvis. There are additional
shadowing echogenic foci in the dilated left renal mid and lower pole calices
that are nonobstructing.
The urinary bladder is distended with urine however neither ureteral jets are
identified.
IMPRESSION:
1. Moderate left hydronephrosis and proximal hydroureter. A 6 mm
nonobstructing calculus is seen within the dilated left renal pelvis.
Additional nonobstructing left renal lower pole calculi also noted. Exact
etiology for obstruction not seen on the scan and it is likely that there is a
distal ureteric obstructing calculus which could be further evaluated by a
noncontrast CT of the abdomen.
2. 2.8 cm simple cyst within the lower pole of the right kidney. No
right-sided hydronephrosis or calculi noted.
Radiology Report
INDICATION: NO_PO contrast; History: ___ with DMII, HTN, and new
pyelonephritis with obstructing stones NO_PO contrast// please evaluate for
other obstructing stones
TECHNIQUE: Multidetector CT images of the abdomen and pelvis were acquired
without intravenous contrast. Non-contrast scan has several limitations in
detecting vascular and parenchymal organ abnormalities, including tumor
detection.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 3.9 s, 51.7 cm; CTDIvol = 14.7 mGy (Body) DLP = 757.3
mGy-cm.
Total DLP (Body) = 757 mGy-cm.
COMPARISON:
Same day ___ renal ultrasound, ___ CTU.
FINDINGS:
Optimal evaluation of organ pathology and vasculature is limited without the
benefit of intravenous contrast.
LOWER CHEST: Atelectasis of the dependent left lung base. Small left pleural
effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogeneous attenuation throughout.
There is no evidence of focal lesions within the limitations of an unenhanced
scan. There is no evidence of intrahepatic or extrahepatic biliary
dilatation. The gallbladder is distended with no radiopaque calculi within
it.
PANCREAS: Extensive pancreatic calcifications and stably dilated main
pancreatic duct measuring 13 mm are consistent with chronic pancreatitis.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: 1.8 x 1.1 cm right adrenal nodule (02:29) is unchanged dating back
to ___.
URINARY:
Right kidney: There is a simple 0.3 cm right renal cyst. No hydronephrosis
seen on the right side. Faint cortical calcification within the right kidney
associated with a scar (601:24) is as before. No renal calculi seen on the
right side.
Left kidney:
There is a duplicated collecting system on the left side.
The superior pole moiety demonstrates mild hydronephrosis with no obstructing
calculi within it.
The lower pole moiety demonstrates presence of multiple nonobstructing calculi
and foci of air within it.
There is a single left ureter formed by ___ of with 2 renal pelves, the left
ureter is dilated in its entire extent secondary to obstruction by a punctate
calculus lodged at the left ureterovesical junction (2:77).
Significant stranding of left perinephric fat associated with urothelial
thickening of the dilated ureter in presence of air locules in the left renal
collecting system are concerning for underlying infection.
GASTROINTESTINAL: There is a small hiatal hernia. The remainder of the
stomach is unremarkable. No bowel obstruction. Large stool burden seen
throughout the colon.
PELVIS: There is a Foley catheter in place with air within the urinary
bladder. There is no free fluid in the pelvis.
REPRODUCTIVE ORGANS: Uterus contains calcified fibroids. There are no adnexal
masses.
LYMPH NODES: There are numerous enlarged left renal hilar and left para-aortic
lymph nodes measuring up to 1.0 cm in short axis (02:34), likely reactive.
VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease
is noted.
BONES: Moderate to severe bilateral hip osteoarthritis and mild multilevel
degenerative disease of the lumbar spine. There is no evidence of worrisome
osseous lesions or acute fracture.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. Duplex left renal collecting system with moderate hydronephrosis of both
the superior and inferior pole moieties. Both moieties have a common ureter
which is obstructed by a punctate calculus lodged at the left ureterovesical
junction. The entire left kidney is enlarged with extensive stranding of
perinephric fat and locules of air within the left renal lower pole collecting
systems concerning for underlying infection. There are multiple
nonobstructing left renal moiety lower pole calculi.
2. Imaging findings of chronic pancreatitis remain unchanged dating back to ___.
3. Stable 1.8 cm incompletely characterized right adrenal nodule is unchanged
dating back ___.
Radiology Report
INDICATION: ___ female with history of HTN, DM, bipolar disease,
nephrolithiasis with prior placement of ureteral stents and lithotripsy,
duplicated bilateral renal collecting system and mild chronic left sided
hydronephrosis. Presents to the ED with abdominal pain, hypotension and fever.
UA positive and US demonstrates moderate left hydronephrosis with a proximal
6mm obstructing stone. We were consulted for placement of a left PCN for
decompression and source control. Left PCN for pyelo
COMPARISON: CT ___
TECHNIQUE: OPERATORS: Dr. ___ and Dr. ___
Interventional ___ and Dr. ___, Interventional Radiology
fellow performed the procedure. Dr. ___ personally supervised
the trainee during any key components of the procedure where applicable and
reviewed and agrees with the findings as reported below.
ANESTHESIA: Anesthesia was provided by the general anesthesia team.
MEDICATIONS:
CONTRAST: 3 ml of Optiray contrast
FLUOROSCOPY TIME AND DOSE: 6.3 minutes, 42 mGy
PROCEDURE: 1. Left ultrasound guided renal collecting system access.
2. Left nephrostogram.
3. 8 ___ nephrostomy tube placement.
PROCEDURE DETAILS: Following the discussion of the risks, benefits and
alternatives to the procedure, written informed consent was obtained from the
health care proxy. The patient was then brought to the angiography suite and
placed prone on the exam table. A pre-procedure time-out was performed per
___ protocol. The left flank was prepped and draped in the usual sterile
fashion.
After the injection of 5 cc of 1% lidocaine in the subcutaneous soft tissues,
the left renal collecting system was accessed through a posterior lower pole
calyx under ultrasound guidance using a 21 gauge Cook needle. Ultrasound
images of the access were stored on PACS. Prompt return of urine confirmed
appropriate positioning. Injection of a small amount of contrast outlined a
dilated renal collecting system. Under fluoroscopic guidance, a Nitinol wire
was advanced into the renal collecting system. After a skin ___, the needle
was exchanged for an Accustick sheath. One the tip of the sheath was in the
collecting system; the sheath was advanced over the wire, inner dilator and
metallic stiffener. The wire and inner dilator were then removed and diluted
contrast was injected into the collecting system to confirm position. A ___
wire was advanced through the sheath and coiled in the collecting system. The
sheath was then removed and a 8 ___ nephrostomy tube was advanced into the
renal collecting system. The wire was then removed and the pigtail was formed
in the collecting system. Contrast injection confirmed appropriate
positioning. The catheter was then flushed, 0 silk stay sutures applied and
the catheter was secured with a Stat Lock device and sterile dressings. The
catheter was attached to a bag.
FINDINGS:
Initial contrast injection demonstrated moderate hydronephrosis of the
inferior moiety collecting system.
Contrast injection demonstrated appropriate final position of a new 8 ___
percutaneous nephrostomy catheter in the renal pelvis of the lower moiety of
the duplicated collecting system.
IMPRESSION:
Successful placement of 8 ___ nephrostomy on the left.
Radiology Report
EXAMINATION: Chest CT.
INDICATION: ___ year old woman with hydronephrosis s/p PCN placement with
difficult intubation and concern for narrowing inferior to vocal cords.//
evaluate for tracheal stenosis
TECHNIQUE: Contiguous axial images were obtained through the chest without
intravenous contrast. Coronal and sagittal reformats were obtained.
COMPARISON: Chest CT ___.
FINDINGS:
HEART AND VASCULATURE: The thoracic aorta is normal in caliber. The heart is
mildly enlarged. The pericardium and great vessels are within normal limits
based on an unenhanced scan. No pericardial effusion is seen. Moderate
coronary artery calcifications.
AXILLA, HILA, AND MEDIASTINUM: No axillary or mediastinal lymphadenopathy is
present. No mediastinal mass or hematoma. The esophagus is patulous.
PLEURAL SPACES: Very small bilateral pleural effusions with associated
atelectasis. No pneumothorax.
LUNGS/AIRWAYS: Evaluation of the lung parenchyma is limited by respiratory
motion. Within this limitation, there is a calcified granuloma of the right
middle lobe (4:158). There is mild but increased atelectasis in the posterior
basilar right lower lobe. The left lower lobe is largely collapsed with
segmental areas of mucus plugging. The trachea is perhaps mildly narrowed
particularly along the mid portion but unchanged. A small dependent secretion
is visible in the mid trachea.
BASE OF NECK: Visualized portions of the base of the neck show no abnormality.
ABDOMEN: Included portion of the unenhanced upper abdomen is unremarkable.
BONES: No suspicious osseous abnormality is seen.? There is no acute fracture.
IMPRESSION:
1. Mild narrowing of the mid trachea.
2. Substantial left lower lobe atelectasis with mucus plugging. Lesser right
lower lobe atelectasis.
3. Very small pleural effusions.
Radiology Report
INDICATION: ___ year old woman s/p ___ guided PCN.// assess proper placement of
PCN.
TECHNIQUE: Portable supine abdominal radiograph was obtained.
COMPARISON: Prior abdominal radiograph dated ___.
FINDINGS:
There are no abnormally dilated loops of large or small bowel.
No evidence of free air on this portable supine radiograph.
Osseous structures are remarkable for degenerative changes in the hips.
Percutaneous nephrostomy tube is seen coiled in overlying the left mid
abdomen. Positioning is similar to that seen on the intraoperative images
(dated ___. Multiple phleboliths in pelvis.
IMPRESSION:
Unchanged positioning of the left-sided percutaneous nephrostomy tube, which
is seen projecting over the left mid abdomen.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Abd pain, Lethargy
Diagnosed with Tubulo-interstitial nephritis, not spcf as acute or chronic
temperature: 102.1
heartrate: 91.0
resprate: 18.0
o2sat: 97.0
sbp: 96.0
dbp: 47.0
level of pain: 10
level of acuity: 2.0 | ___ HOSPITAL COURSE ___
===============================
Ms. ___ is a ___ woman who lives in group home with
HTN, IDDM, bipolar disorder, nephrolithiasis with prior
placement of ureteral stents and lithotripsy, anatomic urologic
anomalies (on macrobid ppx), who presented to the ED w/
abdominal pain, hypotension, and fever.
She was found to have hydronephrosis from an obstructing stone
and urosepsis, now s/p percutaneous nephrostomy tube placement
with ___ and resolution of shock. She presented on ___ from
group home with abdominal pain, fever, and hypotension. In the
ED, she was febrile with SBP ___, elevated Cr, and
positive UA. Renal ultrasound and CT showed left hydronephrosis
with obstructing stone. Urology and ___ were consulted and ___
placed a L PCN tube. She reportedly had a difficult intubation
with the procedure, though was extubated in the PACU without
difficulty. She was admitted to the ___ due to concern for
urosepsis, though she never required pressors. Her urine culture
has grown MDR E coli (sensitive to zosyn and carbapenems). BCx
grew coagulase negative staph. She was initially treated with
vancomycin/zosyn. ID was consulted and felt CoNS was a
contaminant and so vancomycin was discontinued.
FLOOR HOSPITAL COURSE ___
==================================
Upon arrival to floor, she had midline placed on ___ for
projected two weeks of IV antibiotics. Renal function continued
to improved ___ d/t likely ATN plus CKD) to 1.5 on day of
discharge (home baseline likely around 1.0-1.1 per review of
records). She remained afebrile. PCN tube occasionally w/ blood
tinged or fruit punch colored output, which per urology can be
expected as long as she is clinically well and it's still
draining no issues. Her blood sugars were slightly labile
requiring adjustment to home insulin regimen, with plan to
discharge with 6 units of Lantus every morning plus her usual
oral medications, which can be further titrated to usual home
regimen of 8 units daily if food input changes. On day of
discharge she was awake, alert, bright and in no distress w/
sats in mid-90s on room air, labs stable and afebrile for >48
hours. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
distal fibula fracture
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Patient seen and examined and agree with house officer admit
note by Dr. ___ ___ with additions below.
___ year old Female with mild mental retardation, who presents
after falling down 3 steps and fracturing her fibula. The
patient states she was walking down the stairs, and normally
holds the railing very closely, but missed a step and was not
holding on as tightly, so fell down 3 steps. Due to the pain in
her leg, she eventually came to orthopedics clinic who diagnosed
her with a non-displaced fibular fracture. She was sent to the
ED as given her weight bearing status and living on the ___
floor ___, she would need ___ evaluation and likely acute
rehab. She was seen and evaluated in the ED by ___ who felt she
was a risk to fall and would need more extensive stair-training
along with some pain control at acute rehab.
She feels somewhat better today, and is willing for ___ days of
acute rehab.
Past Medical History:
Mental retardation, tubal ligation, knee surgery, depression,
dysmenorrhea, headaches, low back pain, asthma
Social History:
___
Family History:
Cousin: Cancer of unknown type
Physical Exam:
Admission:
ROS:
GEN: - fevers, - Chills, - Weight Loss
EYES: - Photophobia, - Visual Changes
HEENT: - Oral/Gum bleeding
CARDIAC: - Chest Pain, - Palpitations, - Edema
GI: - Nausea, - Vomitting, - Diarhea, - Abdominal Pain, -
Constipation, - Hematochezia
PULM: - Dyspnea, - Cough, - Hemoptysis
HEME: - Bleeding, - Lymphadenopathy
GU: - Dysuria, - hematuria, - Incontinence
SKIN: - Rash
ENDO: - Heat/Cold Intolerance
MSK: - Myalgia, + Arthralgia, - Back Pain
NEURO: - Numbness, - Weakness, - Vertigo, - Headache
PHYSICAL EXAM:
VSS: 99.1, 132/81, 94, 24, 94%
GEN: NAD, Obese
Pain: ___
HEENT: EOMI, MMM, - OP Lesions
PUL: CTA B/L
COR: RRR, S1/S2, - MRG
ABD: Massive ventral hernia, NT, +BS, - CVAT
EXT: - CCE, Left leg in cast to knee with boot
NEURO: CAOx3
Discharge:
Vitals: 99 138/77 70 20 95%RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI
Neck: supple
Abdomen: Bowel signs positive, midline abdominal surgical scar
noted, distended due to ventral hernia, soft, non-tender, no
rebound or guarding
GU: no foley
Ext: Warm, well perfused, no clubbing, cyanosis or edema. L leg
in cast to knee with boot, good cap refill
Neuro: CNII-XII intact, able to move toes in left leg cast
Pertinent Results:
ANKLE (AP, LAT & OBLIQUE) LEFT Study Date of ___ 3:54 ___
IMPRESSION:
Nondisplaced intra-articular distal fibula fracture, consistent
with Weber B fracture.
Medications on Admission:
1. Acetaminophen 500 mg PO Q6H:PRN pain
2. Alendronate Sodium 35 mg PO QFRI
3. Omeprazole 20 mg PO DAILY
4. Vitamin D 1000 UNIT PO DAILY
5. Albuterol Inhaler 2 PUFF IH PRN DYSPNEA shortness of breath
(per pharmacy she has not filled this in months)
Discharge Medications:
1. Acetaminophen 500 mg PO Q6H:PRN pain
2. Alendronate Sodium 35 mg PO QFRI
3. Omeprazole 20 mg PO DAILY
4. Vitamin D 1000 UNIT PO DAILY
5. Albuterol Inhaler 2 PUFF IH PRN DYSPNEA shortness of breath
(per pharmacy she has not filled this in months)
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnoses:
Fall
Distal fibular fracture
Secondary diagnoses:
Developmental delay
ventral hernia
eczema
asthma
depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
HISTORY: Fall and ankle swelling.
COMPARISON: None available.
FINDINGS:
3 views of left ankle. There is a nondisplaced transverse fracture through
the distal fibula which extends into the ankle joint. The ankle mortise is
intact. There is soft tissue swelling about the lateral malleolus. There are
superior and inferior calcaneal enthesophytes. There is mild spurring at the
tarsometatarsal joints.
IMPRESSION:
Nondisplaced intra-articular distal fibula fracture, consistent with Weber B
fracture.
These findings were discussed with Dr. ___ by Dr. ___ for 4:20pm
on ___ via telephone at time of discovery.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: S/P FALL
Diagnosed with FX ANKLE NOS-CLOSED, FALL FROM OTHER SLIPPING,TRIPPING,STUMBLING
temperature: 97.4
heartrate: 60.0
resprate: 16.0
o2sat: 98.0
sbp: 156.0
dbp: 83.0
level of pain: 0
level of acuity: 3.0 | ASSESSMENT AND PLAN: ___ with mild mental retardation admitted
after a fall with left fibula fracture for pain management,
awaiting rehab placement.
# L Ankle fx: Mechanical fall in the setting of missing a step
while going down the steps. No complaints of lightheadedness,
dizziness to necessitate a syncope workup. Apparently falls
often, followed by ___. She lives on the ___ floor. Pt was seen
by Orthopedics in clinic and fracture was stabilized in a cast.
Orthopedics recommended touchdown weightbearing to left foot.
She was sent to the ED and admitted for rehab disposition. Seen
by ___ in the ED, agreed that she needed rehab. She was given
Tylenol for pain. Given that she lives on the third floor alone,
she requires stair training, home safety eval, and physical
therapy at rehab. She also will benefit from a home safety eval.
These plans were coordinated with her outpatient social worker
___ at the department of developmental
services who did say they have been trying to convince her to
move to elder housing without stairs. This process should be
continued at rehab.
# Ventral Hernia. Chronic complication of abdominal surgery. On
the day of discharge she vomited once but she felt well, was
passing stool, was otherwise not nauseous. Her abdominal exam
was unchanged and reassuring.
# Migraines. Chronic since adolesence. Pt admits to trying
multiple migraine medicines without any relief. She was offered
Tylenol as needed for any headaches
# Asthma: Given prn albuterol. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Pancytopenia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ yo M with recent diagnoses of high-grade large cell
neuroendocrine lung carcinoma complicated by malignant pleural
effusion on C1D14 of carboplatin/etoposide who presents with
pancytopenia.
Patient was recently admitted at ___ from ___ to ___. During
that admission, diagnosis of lung cancer was made by
thoracentesis with pleural fluid cytology. Patient was started
on carboplatin/etoposide in house, first day ___. Hospital
course was complicated by acute hypoxic respiratory failure,
thought to be due to a combination of malignant pleural effusion
and HCAP, s/p thoracentesis, multiple chest tubes, and 8 day
course of levofloxacin. Other chronic issues were stable during
hospitalization. Patient received Neupogen day 4 and onward with
appropriate response in counts.
Today, patient presented for labs and was found to be markedly
pancytopenic for which he was referred to the ED.
In the ED, initial vital signs were 98.4, 60, 106/48, 16, 99%
NC. Initial labs were remarkable for WBC 17.8 -> 2.0, Hgb 8.8 ->
6.1, and Plt 110 -> 23, prior CBC on ___. ___ Oncology was
consulted, and patient was admitted to OMED for further
management.
Past Medical History:
CAD, s/p CABG (cardiologist Dr ___
? CHF
Lung mass
Osteoarthritis
Long-term anticoagulation use
Depression
Schatzki's ring s/p dilation, last endoscopy ___
Pancytopenia
Peripheral vascular disease
Diverticulitis
Esophageal motility disorder
Atrial fibrillation
Thrombocytopenia
Hypertension
Hypercholesterolemia
Gout
Macrocytosis
BPH
Glaucoma
Central retinal vein occlusion
Social History:
___
Family History:
No family history of blood diseases. Mother died of pancreatic
cancer
Physical Exam:
ON ADMISSION:
================
vital signs were 73, 114/48, ___, 100% NC.
GENERAL: Pleasant, lying in bed comfortably
HEENT:
CARDIAC: Regular rate and rhythm, no murmurs, rubs, or gallops
LUNG: Appears in no respiratory distress, clear to auscultation
bilaterally, no crackles, wheezes, or rhonchi
ABD: Normal bowel sounds, soft, nontender, nondistended, no
hepatomegaly, no splenomegaly
EXT: Warm, well perfused, no lower extremity edema
PULSES: 2+ radial pulses, 2+ ___ pulses, 2+ DP pulses
NEURO: Alert, oriented, CN II-XII intact, motor and sensory
function grossly intact
SKIN: No significant rashes
ON DISCHARGE:
=================
vs: 97.7 117-99/43-59 ___ 95% ON 1.5l nc
GENERAL: Pleasant, lying in bed comfortably
HEENT:
CARDIAC: Regular rate and rhythm, no murmurs, rubs, or gallops
LUNG: Appears in no respiratory distress, clear to auscultation
bilaterally, no crackles, wheezes, or rhonchi
ABD: Normal bowel sounds, soft, nontender, nondistended, no
hepatomegaly, no splenomegaly
EXT: Warm, well perfused, no lower extremity edema
PULSES: 2+ radial pulses, 2+ ___ pulses, 2+ DP pulses
NEURO: Alert, oriented, CN II-XII intact, motor and sensory
function grossly intact
SKIN: No significant rashes
Pertinent Results:
LABS
___ 09:02PM WBC-1.8* RBC-2.20* HGB-6.9* HCT-21.4* MCV-97
MCH-31.4 MCHC-32.2 RDW-19.7* RDWSD-65.1*
___ 01:45PM GLUCOSE-96 UREA N-13 CREAT-0.7 SODIUM-138
POTASSIUM-3.8 CHLORIDE-99 TOTAL CO2-29 ANION GAP-14
___ 01:45PM estGFR-Using this
___ 01:45PM CALCIUM-8.4 PHOSPHATE-4.1 MAGNESIUM-1.9
___ 01:45PM WBC-2.0*# RBC-1.97*# HGB-6.1*# HCT-19.8*#
MCV-101* MCH-31.0 MCHC-30.8* RDW-19.5* RDWSD-66.2*
___ 01:45PM NEUTS-30* BANDS-1 ___ MONOS-24* EOS-1
BASOS-1 ATYPS-1* ___ MYELOS-3* AbsNeut-0.62* AbsLymp-0.80*
AbsMono-0.48 AbsEos-0.02* AbsBaso-0.02
___ 01:45PM HYPOCHROM-1+ ANISOCYT-2+ POIKILOCY-1+
MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-1+ OVALOCYT-1+
___ 01:45PM PLT SMR-VERY LOW PLT COUNT-23*#
___ 01:45PM ___ PTT-36.4 ___
___ 10:45AM BLOOD WBC-2.2* RBC-2.36* Hgb-7.4* Hct-23.3*
MCV-99* MCH-31.4 MCHC-31.8* RDW-20.7* RDWSD-64.4* Plt Ct-24*
___ 02:57PM BLOOD Glucose-104* UreaN-11 Creat-0.6 Na-135
K-3.2* Cl-96 HCO3-29 AnGap-13
___ 02:57PM BLOOD Calcium-8.5 Phos-3.2 Mg-1.8
IMAGING
1. Small left pleural effusion likely slightly improved from ___.
2. Mild pulmonary edema improved from ___.
3. Vague bilateral opacities could represent developing
pneumonia or
combination of atelectasis and pulmonary edema.
CULTURES:
NONE
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 10 mg PO QPM
4. Furosemide 40 mg PO DAILY
5. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
6. Metoprolol Succinate XL 12.5 mg PO DAILY
7. Multivitamins 1 TAB PO DAILY
8. Omeprazole 20 mg PO BID
9. Sertraline 200 mg PO DAILY
10. Tamsulosin 0.4 mg PO QHS
11. Timolol Maleate 0.5% 1 DROP BOTH EYES DAILY
12. Vitamin D ___ UNIT PO DAILY
13. Acetaminophen 650 mg PO Q8H:PRN pain
14. Docusate Sodium 100 mg PO BID
15. Heparin 5000 UNIT SC BID
16. LOPERamide 2 mg PO TID:PRN diarrhea
17. Polyethylene Glycol 17 g PO DAILY:PRN constipation
18. Senna 17.2 mg PO BID:PRN constipation
19. TraZODone 50 mg PO QHS:PRN Insomnia
Discharge Medications:
1. Acetaminophen 650 mg PO Q8H:PRN pain
2. Allopurinol ___ mg PO DAILY
3. Atorvastatin 10 mg PO QPM
4. Docusate Sodium 100 mg PO BID
5. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
6. LOPERamide 2 mg PO TID:PRN diarrhea
7. Metoprolol Succinate XL 12.5 mg PO DAILY
8. Multivitamins 1 TAB PO DAILY
9. Omeprazole 20 mg PO BID
10. Polyethylene Glycol 17 g PO DAILY:PRN constipation
11. Senna 17.2 mg PO BID:PRN constipation
12. Sertraline 200 mg PO DAILY
13. Tamsulosin 0.4 mg PO QHS
14. Timolol Maleate 0.5% 1 DROP BOTH EYES DAILY
15. TraZODone 50 mg PO QHS:PRN Insomnia
16. Vitamin D ___ UNIT PO DAILY
17. Furosemide 40 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
pancytopenia secondary to chemotherapy
acute on chronic systolic diastolic heart failure.
Large cell neuroendocrine lung carcinoma
coronary artery disease
Glaucoma
Depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ year old man with neutropenia and shortness of breath // does
this patient have pneumonia or worsening of his effusion?
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph from ___.
CT of the chest from ___.
FINDINGS:
Lung volumes are slightly increased with residual bibasilar atelectasis. Mild
pulmonary edema is improved from ___. The left apical mass-like opacity is
unchanged. Multiple vague opacities may represent combination of atelectasis
and edema or evolving pneumonia. A small left pleural effusion is likely
improved from ___ but difficult to assess given differences in technique.
No substantial right pleural effusion. Postoperative mediastinal contours and
cardiac borders are stable.
IMPRESSION:
1. Small left pleural effusion likely slightly improved from ___.
2. Mild pulmonary edema improved from ___.
3. Vague bilateral opacities could represent developing pneumonia or
combination of atelectasis and pulmonary edema.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Abnormal labs, Transfer
Diagnosed with Malignant neoplasm of unsp part of unsp bronchus or lung
temperature: 98.4
heartrate: 60.0
resprate: 16.0
o2sat: 99.0
sbp: 106.0
dbp: 48.0
level of pain: 0
level of acuity: 2.0 | ___ yo M with recent diagnoses of high-grade large cell
neuroendocrine lung carcinoma complicated by malignant pleural
effusion on C1D14 of carboplatin/etoposide who presents with
pancytopenia.
during his hospital stay the patient complained of shortness of
breath at rest as well as on exertion. His Hb on admission was
6.1 and he showed pancytopenia. therefore 2 units of blood where
given. This was complicated with mild puomonary edema manifested
as shortness of breath. He was given 40mg IV Lasix with good
response. His Hb after the 2 unit transfusion ncreased to 7.4
and remained stable. He did not have evidence of bleeding or
other cause of blood loss. the cause of his pancytopenia is
thought to be from his chemotherapy since his admission
corresponds to the nadir of his chemo therapy.
the patient was continued on his home medication including his
statins. however we stopped his ASA because of low Plt. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Bacitracin / Ciprofloxacin
Attending: ___
Chief Complaint:
Palpitations
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with a history of hypertension, dyslipidemia, CAD, atrial
fibrillation (on warfarin), bilateral breast cancers s/p
mastectomies (___), LUL NSCLC (___) s/p lobectomy and
RUL NSCLC (___) s/p CyperKnife therapy, left atrial clot, who
presents with atrial fibrillation with rapid ventricular rate
(RVR). She awoke the morning of admission with increased
fatigue. She had difficulty going about her daily routine at
home. She noted a pounding and fast heartbeat. This was
associated with dizziness and lightheadedness. She felt
increasingly weak and felt that her BP must be low. She denied
chest pain, shortness of breath, nausea. She called EMS who
noted HR in the 170s and SBP 90. On arrival to the ED, she
reported feeling terrible, like she is "going to die". She has a
recent diagnosis of atrial fibrillation.
Of note, earlier this month, her metoprolol (75 mg daily) was
stopped in the setting of orthostatic hypotension noted at an
oncology office visit. Further review of one of the EKGs at that
visit noted atrial fibrillation with RVR, so metoprolol was
restarted, though at a lower dose (12.5 mg BID).
In the ED, initial vitals were SBP 80-90s, VR 170s, SpO2 98% on
RA. Her EKG showed atrial fibrillation with RVR. CXR did not
show any acute changes from baseline. Labs were notable for WBC
11.9, INR 2.4. Cardiology was consulted. Patient was given 2 L
NS, metoprolol 5 mg IV x 2, metoprolol 50 mg PO. VR came down to
low 100s and BP was 103/71. She was admitted to cardiology for
further management of atrial fibrillation and uptitration of
beta blockade.
Past Medical History:
1. CAD RISK FACTORS: Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
-atrial fibrillation on warfarin
-positive ETT in ___ but subsequent ETTs negative
3. OTHER PAST MEDICAL HISTORY:
- ___ x2 (___), on home O2 (2 Lpm NC continuously)
- ___ s/p LUL lobectomy (stage IA NSCLC), no post XRT/chemo
- ___ recurrence on RUL (CT/PET), mucinous adenocarcinoma s/p
CyberKnife radiation, s/p recurrence and initiation of
pemetrexed ___
- Bilateral breast CA (___) s/p R mastectomy (___) and L
mastectomy (___). No XRT.
- Depression
- Memory impairment
- Osteoporosis
- Seizure disorder
- Seborrheic dermatitis
- Enchondroma
- h/o ankle fracture
Social History:
___
Family History:
Her father died at age ___ of "old age." He had a stroke earlier
in life. Her mother died at age ___ of "old age." She suffered
from hyperlipidemia and diabetes later in life. She has one
brother and two sons. One of her sons died of presumed sudden
cardiac death at the age of ___, but she does not know the
details. There is no family history notable for hypertension.
Physical Exam:
On admission
General: Elderly Caucasian woman in NAD, pleasant, sitting
comfortably in bed
VS: T 97.5 BP 98/63 HR 96 RR 12 SaO2 99% on 2 Lpm via NC
HEENT: NC/AT, PERRL, sclera anicteric, no conjunctival
injection, oropharynx clear
Neck: supple, no LAD, no JVP elevation, no carotid bruits
CV: Tachycardic, irregularly irregular rhythm, normal s1 and s2;
no murmurs, rubs or gallops
Lungs: good effort, clear bilaterally
Abdomen: soft, nontender, nondistended, normoactive bowel sounds
GU: no Foley
Ext: warm, well perfused, no edema
Neuro: oriented x 3, alert and appropriate affect, moves all 4
extremities symmetrically
Skin: warm, no lesions or rash
At discharge
General: pleasant elderly woman sitting comfortably in bed in
NAD
VS: T 97.3 BP 135/64 (130s-150s/60s) HR 78 (60s-70s) RR 20 SaO2
96% on 3 Lpm NC
Tele: NSR in ___
Unchanged from admission, except as noted below
CV: RRR, normal s1 and s2; no murmurs, rubs or gallops
Lungs: good effort, scattered rhonchi, no crackles or wheezes
Pertinent Results:
___ 08:40AM BLOOD WBC-11.9*# RBC-4.36 Hgb-11.3* Hct-36.2
MCV-83 MCH-26.0* MCHC-31.2 RDW-15.8* Plt ___
___ 08:40AM BLOOD Neuts-77.6* Lymphs-15.6* Monos-5.4
Eos-0.8 Baso-0.6
___ 09:00AM BLOOD ___ PTT-37.7* ___
___ 08:40AM BLOOD Glucose-139* UreaN-11 Creat-0.8 Na-137
K-4.3 Cl-95* HCO3-25 AnGap-21*
___ 08:40AM BLOOD Calcium-9.2 Phos-3.2 Mg-1.9
___ 08:40AM BLOOD Phenyto-1.1*
___ 8:41:04 AM ECG
Atrial fibrillation with a rapid ventricular response. Right
bundle-branch block. Left anterior hemiblock. Non-specific ST-T
wave changes. Compared to the previous tracing of ___ the
heart rate is faster.
___ PORTABLE CXR
Single AP upright portable view of the chest was obtained.
Fiducial marker is again seen overlying the right upper chest
with underlying large opacity in this patient with known
malignancy, grossly similar to prior. Increased interstitial
markings in a background of pulmonary emphysema are again seen.
The lungs remain hyperinflated. Patient's known left-sided chain
sutures are obscured by overlying external artifact. No definite
new focal consolidation is seen. There is no large pleural
effusion or evidence of pneumothorax. The cardiac and
mediastinal silhouettes are stable. There is diffuse osteopenia.
Sclerotic foci projecting over the left glenoid and partially
imaged proximal left humerus are stable.
IMPRESSION: No significant interval change.
___ Echocardiogram
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. The estimated right atrial pressure
is ___ mmHg. Left ventricular wall thickness, cavity size and
regional/global systolic function are normal (LVEF >60%). The
estimated cardiac index is normal (>=2.5L/min/m2). Right
ventricular chamber size and free wall motion are normal. The
aortic arch is mildly dilated. The aortic valve leaflets (3)
appear structurally normal with good leaflet excursion and no
aortic stenosis or aortic regurgitation. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. No mitral regurgitation is seen. [Due to acoustic
shadowing, the severity of mitral regurgitation may be
significantly UNDERestimated.] The tricuspid valve leaflets are
mildly thickened. The pulmonary artery systolic pressure could
not be determined. There is an anterior space which most likely
represents a prominent fat pad.
IMPRESSION: Normal biventricular cavity sizes with preserved
global and regional biventricular systolic function. Mildly
dilated aortic arch
DISCHARGE LABS
___ 09:00AM BLOOD WBC-6.3 RBC-4.20 Hgb-10.6* Hct-34.5*
MCV-82 MCH-25.2* MCHC-30.7* RDW-15.8* Plt ___
___ 09:00AM BLOOD ___
___ 09:00AM BLOOD Glucose-125* UreaN-9 Creat-0.6 Na-138
K-3.9 Cl-99 HCO3-25 AnGap-18
___ 09:00AM BLOOD Calcium-8.8 Phos-3.3 Mg-1.7
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ondansetron 4 mg PO Q8H:PRN nausea
2. Acetaminophen 325 mg PO Q6H:PRN pain
3. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN shortness of breath
/ wheezing
4. Benzonatate 100 mg PO TID:PRN cough
5. Guaifenesin-CODEINE Phosphate ___ mL PO Q6H:PRN cough
6. QUEtiapine Fumarate 25 mg PO QHS
7. Metoprolol Tartrate 12.5 mg PO BID
8. Docusate Sodium 100 mg PO BID:PRN constipation
9. Warfarin 2.5 mg PO DAILY16
10. Phenytoin Sodium Extended 100 mg PO BID
11. Multivitamins 1 TAB PO DAILY
12. Omeprazole 20 mg PO BID
13. Aspirin 81 mg PO DAILY
14. Venlafaxine XR 225 mg PO DAILY
15. FoLIC Acid 1 mg PO DAILY
16. Simvastatin 40 mg PO DAILY
17. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit oral DAILY
18. Sodium Chloride Nasal ___ SPRY NU QID:PRN nasal symptoms
19. Lorazepam 0.5 mg PO ONCE:PRN prior to imaging studies for
anxiety
20. Milk of Magnesia 5 mL PO DAILY:PRN constipation
Discharge Medications:
1. Acetaminophen 325 mg PO Q6H:PRN pain
2. Aspirin 81 mg PO DAILY
3. Benzonatate 100 mg PO TID:PRN cough
4. Docusate Sodium 100 mg PO BID:PRN constipation
5. FoLIC Acid 1 mg PO DAILY
6. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN shortness of breath
/ wheezing
7. Metoprolol Tartrate 12.5 mg PO BID
8. Multivitamins 1 TAB PO DAILY
9. Omeprazole 20 mg PO BID
10. Phenytoin Sodium Extended 100 mg PO BID
11. QUEtiapine Fumarate 25 mg PO QHS
12. Venlafaxine XR 225 mg PO DAILY
13. Amiodarone 200 mg PO BID
RX *amiodarone 200 mg 1 tablet(s) by mouth two times a day for 5
days and 1 time a day thereafter Disp #*40 Tablet Refills:*0
14. Guaifenesin-CODEINE Phosphate ___ mL PO Q6H:PRN cough
15. Ondansetron 4 mg PO Q8H:PRN nausea
16. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit oral DAILY
17. Lorazepam 0.5 mg PO ONCE:PRN prior to imaging studies for
anxiety
18. Milk of Magnesia 5 mL PO DAILY:PRN constipation
19. Sodium Chloride Nasal ___ SPRY NU QID:PRN nasal symptoms
20. Warfarin 1 mg PO 4X/WEEK (___)
First dose on ___. Atorvastatin 20 mg PO DAILY
22. Warfarin 2 mg PO 3X/WEEK (___)
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Atrial fibrillation with rapid ventricular rate
Sinus bradycardia with pauses
Hypertension
Dsylpidemia
Non-small cell lung cancer
Depression
Seizure disorder
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAM: Chest, single AP upright portable view.
CLINICAL INFORMATION: Dyspnea.
___.
FINDINGS: Single AP upright portable view of the chest was obtained.
Fiducial marker is again seen overlying the right upper chest with underlying
large opacity in this patient with known malignancy, grossly similar to prior.
Increased interstitial markings in a background of pulmonary emphysema are
again seen. The lungs remain hyperinflated. Patient's known left-sided chain
sutures are obscured by overlying external artifact. No definite new focal
consolidation is seen. There is no large pleural effusion or evidence of
pneumothorax. The cardiac and mediastinal silhouettes are stable. There is
diffuse osteopenia. Sclerotic foci projecting over the left glenoid and
partially imaged proximal left humerus are stable.
IMPRESSION: No significant interval change.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: DIZZINESS
Diagnosed with ATRIAL FIBRILLATION
temperature: nan
heartrate: 175.0
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: 1.0 | Mrs. ___ was admitted with palpitations, fatigue, and
dyspnea. She was found to be in atrial fibrillation with a rapid
ventricular rate. She received beta blockade, converted into
sinus rhythm but had a long conversion pause and subsequent
symptomatic sinus pauses. She was started on amiodarone and
continued on low dose metoprolol. She had no recurrence of sinus
pauses and was discharged with ___ monitor and follow-up with
Dr. ___ in ___ clinic.
ACTIVE ISSUES
# Atrial Fibrillation: Patient has a history of atrial
fibrillation. She presented with palpitations and was in atrial
fibrillation with RVR. She received both IV and PO metoprolol
for rate control. She spontaneously converted but had long sinus
pauses on AV nodal blockers and was symtomatic with blood
pressures dipping into ___ systolic. She was very
uncomfortable when going fast in atrial fibrillation as well. EP
was consulted and recommended starting amiodarone and continuing
on low-dose metoprolol for rate control if she went back into
atrial fibrillation. After starting amiodarone, she remained in
sinus rhythm and did not have additional pauses. She may be a
candidate for pacemaker in the future, depending upon any future
plans for chemotherapy (which may impair wound healing) or
radiation (which may impact the site of pacemaker placement).
She was continued on warfarin for stroke prevention, although in
the setting of starting amiodarone will need close monitoring of
INR in the several days after discharge and a decrease of her
prior warfarin dose (2.5 mg daily) by likely ___. She was
dishcarged on 200 mg amiodarone BID x 1 week and then 200 mg
daily thereafter, with ___ of Hearts monitor and follow-up
with Dr. ___ in 1 month.
CHRONIC ISSUES
# Depression: Stable, continued home venlafaxine and quetiapine.
# Lung cancer: Patient has recurrence of RUL mucinous
adenocarcinoma after CyberKnife resection in ___. She is
currently undergoing palliative chemotherapy with pemetrexed.
Will defer furthur management to outpatient oncologist.
# Seizure disorder: Stable, continued home pheyntoin.
# Hyperlipidemia: Stable, changed from simvastatin to
atorvastatin secondary to interaction with amiodarone.
TRANSITIONAL ISSUES
- Should have frequent INR checks in the week after discahrge to
determine an appropriate new warfarin regimen given that she was
started on amiodarone (has recent TSH and we obtained baseline
LFTs)
- Discharged on ___ monitor and to follow-up with Dr. ___ in 1
month
- Once discharged from ___ facility, may need more
home services that were being arranged just prior to this
admission
- Changed simvastatin to atorvastatin given interaction with
amiodarone
- Patient was full code |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
fever
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is an ___ gentleman with a pmhx. significant for
stage IV rectal CA (s/p LAR in ___, now with liver mets and
receiving FOLFOX) and recent port-a-cath placement on ___ who
is admitted from the ED for general malaise and fatigue and a
fever to 101.3 at home.
Mr. ___ had recent left subclavian indwelling port
placement
port placement on ___ and received FOLFOX on ___. He was
seen by a ___ on day of admission whereupon his port was
accessed and chemo infusion was stopped; he was told that he had
a low grade fever and that he should continue checking it
throughout the day. Patient subsequently had a temperature of
101.3 and was told by his oncologist to present to the emergency
department.
Mr. ___ states that since his port placement he has felt
tired; however, he thinks this might be related to the
chemotherapy as well. He did not notice overt fevers at home
(until the day of admission) but did notice chills on the night
of ___. He denies any chest pain, shortness of breath, nausea,
vomiting, diarrhea, blood in his stools, or other concerning
signs or symptoms.
In the ED, initial vitals were: 98.7 82 93/67 16 97% RA. The
ED was unable to access patient's port and 2 blood cultures were
drawn peripherally. Recieved NS (though unclear how much).
Patient was given 1 dose of vancomycin over concern for port
infection.
Past Medical History:
ONCOLOGIC HISTORY:
Diagnosed with rectal cancer in ___ after being found to have
heme positive stools and colonoscopy showed mass at 22cm.
Biopsy revealed adenocarcinoma and he underwent LAR on ___.
Staged as a Dukes C and would be a stage III cancer by current
staging. This was a T2, N1lesion and he was placed on a
research protocol. He received concurrent ___ and radiation.
He underwent multiple repeat
colonoscopies following this and had no evidence of disease. He
was followed from ___, at the time of diagnosis, until ___, at
which time he was ___ years out and it was determined that he
needed no further followup.
Recently underwent cardiac MRI for bradycardia and PVCs to
evaluate LV function on ___, it was incidentally noted
that he had a concerning area within the liver concerning for
liver tumor. This lesion measured 8.9 x 7.1 cm and there is a
second small lesion in the dome of the liver measuring 1.3 x 1.0
cm. He was set up for an ultrasound-guided biopsy of this,
which was performed on ___ and the pathology of this was
noted to be metastatic adenocarcinoma,
morphologically consistent with his primary previous tumor;
however, also could be a new tumor. Currently undergoing
treatment with FOLFOX. Last cycle on ___.
PAST MEDICAL HISTORY:
--Hypertension
--Vitamin D deficiency
--GERD
--Obesity
--Hypothyroidism
--Rectal cancer s/p colon resection surgery, radiation, now
receiving FOLFOX
--Bradycardia
--Depression
--Glucose intolerance
--Neck and lower back pain
--Prostatic hypertrophy s/p TURP and prostatectomy
--CPPD / pseudogout
--Anemia / chronic
--Erectile dysfunction
--s/p hernia repair.
Social History:
___
Family History:
Father died of leukemia. Mother died at ___
of natural causes. One sister died with pancreatic cancer.
Three children, one daughter died from cancer related to a drug
prescribed to the mother during the pregnancy.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 99.6, 118/66, 76, 16, 94% on RA
GENERAL: Well appearing man, looks younger than stated age, no
acute distress
HEENT: Mucous membranes moist, no lesions
CHEST: CTA bilaterally, no wheezes, rales, or rhonchi,
seborrheic keratosis on back
CARDIAC: RRR, normal S1 and S2, II/IV systolic murmur
ABDOMEN: +BS, obese, non-tender, non-distended
EXTREMITIES: No edema bilaterally
PORT SITE: Port in place in left upper subclavian region, no
erythema, no fluctuance
NEURO: Alert and oriented x3
DISCHARGE PHYSICAL EXAM:
Vitals - 98.1-99.8, 130/60, 64, 18, 97/RA
GENERAL: Well appearing man
HEENT: Mucous membranes moist, no lesions
CHEST: CTA bilaterally
CARDIAC: RRR, normal S1 and S2, II/IV systolic murmur
ABDOMEN: +BS, obese, non-tender, non-distended
EXTREMITIES: No edema bilaterally
PORT SITE: Port in place in left upper subclavian region, no
erythema, no fluctuance. Some areas of hematoma in vicinity of
port.
Pertinent Results:
___ 08:33PM BLOOD WBC-13.2*# RBC-4.41* Hgb-14.1 Hct-42.1
MCV-95 MCH-31.9 MCHC-33.4 RDW-14.9 Plt ___
___ 03:23AM BLOOD WBC-10.3 RBC-4.00* Hgb-12.5* Hct-37.2*
MCV-93 MCH-31.4 MCHC-33.8 RDW-14.6 Plt ___
___ 03:23AM BLOOD ALT-29 AST-56* LD(___)-650* AlkPhos-151*
TotBili-3.1* DirBili-0.7* IndBili-2.4
___ 07:46AM BLOOD ALT-25 AST-46* LD(LDH)-568* AlkPhos-155*
TotBili-3.6*
___ 06:00AM BLOOD ALT-23 AST-32 LD(___)-435* AlkPhos-176*
TotBili-3.6*
___ 07:50AM BLOOD ALT-27 AST-32 LD(LDH)-349* AlkPhos-310*
TotBili-4.1*
___ 06:00AM BLOOD ALT-31 AST-35 LD(LDH)-292* AlkPhos-385*
TotBili-2.8*
IMAGING:
CXR ___: no evidence of acute disease
RUQ U/S ___:
IMPRESSION:
1. Cholelithiasis without evidence of acute cholecystitis. No
bile duct
dilation.
2. Hypoechoic area in the medial right hepatic lobe likely
corresponds to
known metastasis, incompletely evaluated. This study does not
evaluate for
new liver metastases and if further evaluation is desired, CT or
MRI should be
performed.
MRCP ___:
FINDINGS: Again visualized is a large heterogeneous T2 bright
mass in the
central right hepatic lobe at the hilum, with peripheral rim
hyperenhancement
and central T1 and T2 dark signal, measuring approximately 9.2 x
9.7 x 9.5 cm,
demonstrating interval growth since prior CT torso of ___.
Multiple
small satellite nodules are seen adjacent and just superior and
lateral to the
dominant mass which appear unchanged. Mild intrahepatic biliary
ductal
dilatation which is likely secondary to obstruction from the
dominant tumor
mass.
The visualized branches of the portal venous system appear
patent. There is
compression of the middle hepatic vein by the large mass,
displacing the vein
anteriorly. The right hepatic vein appears to traverse through
the mass and
is completely encompassed by it. Patent splenic vein and
superior mesenteric
veins. Normal-appearing spleen, pancreas, bilateral adrenal
glands.
Bilateral simple-appearing renal cortical cysts as well as large
left renal
parapelvic cyst, unchanged. Small subcentimeter periportal
lymph nodes.
Cholelithiasis again noted. No evidence of choledocholithiasis.
Visualized
small and large bowel unremarkable. No evidence of ascites.
IMPRESSION:
1. Interval growth of large rim-enhancing mass in the liver
hilum, with
multiple small satellite nodules, consistent with patient's
history of
metastatic colon cancer.
2. Cholelithiasis without evidence of choledocholithiasis.
3. Bilateral simple renal cysts, unchanged.
Medications on Admission:
. Information was obtained from .
1. Ondansetron 8 mg PO Q8H:PRN Nausea
2. Lorazepam 0.5 mg PO Q8H:PRN Nausea
Please hold for oversedation.
3. Prochlorperazine 10 mg PO Q6H:PRN Nausea
4. Allopurinol ___ mg PO DAILY
5. BuPROPion (Sustained Release) 300 mg PO QAM
6. Carvedilol 3.125 mg PO BID
Please hold for SBP <100 or HR <55.
7. Colchicine 0.6 mg PO DAILY
8. Hydrochlorothiazide 25 mg PO DAILY
9. Levothyroxine Sodium 75 mcg PO DAILY
10. Omeprazole 20 mg PO DAILY
11. Trandolapril 4 mg PO DAILY
Please hold for SBP <100.
12. Vitamin D ___ UNIT PO DAILY
13. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN Pain
Please hold for oversedation
14. Aspirin 325 mg PO DAILY
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. BuPROPion (Sustained Release) 300 mg PO QAM
3. Carvedilol 3.125 mg PO BID
Please hold for SBP <100 or HR <55.
4. Colchicine 0.6 mg PO DAILY
5. Hydrochlorothiazide 25 mg PO DAILY
6. Levothyroxine Sodium 75 mcg PO DAILY
7. Lorazepam 0.5 mg PO Q8H:PRN Nausea
Please hold for oversedation.
8. Omeprazole 20 mg PO DAILY
9. Ondansetron 8 mg PO Q8H:PRN Nausea
10. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN Pain
Please hold for oversedation
11. Prochlorperazine 10 mg PO Q6H:PRN Nausea
12. Trandolapril 4 mg PO DAILY
Please hold for SBP <100.
13. Vitamin D ___ UNIT PO DAILY
14. Aspirin 325 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Fever
Colon cancer
Hyperbilirubinemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
CHEST RADIOGRAPHS
HISTORY: Fever.
COMPARISONS: ___.
TECHNIQUE: Chest, PA and lateral.
FINDINGS: A left-sided Port-A-Cath terminates in the superior vena cava, as
before. The cardiac, mediastinal and hilar contours appear unchanged. There
is no pleural effusion or pneumothorax. The lungs appear clear. Mild
hyperinflation is present. The lungs appear clear. Mild degenerative changes
are similar along the mid-to-lower thoracic spine.
IMPRESSION: No evidence of acute disease.
Radiology Report
INDICATION: ___ man with metastatic colon cancer to liver with mildly
elevated LFTs and recent abdominal pain and fevers.
COMPARISON: CT ___.
FINDINGS: Targeted right upper quadrant ultrasound was performed. Note, the
liver was not fully evaluated, specifically to assess for metastatic disease.
A hypoechoic area in the medial right hepatic lobe likely corresponds to the
known large liver metastasis, incompletely evaluated on this study. There is
no intra- or extra-hepatic bile duct dilation. Shadowing, mobile gallstones
are seen within the gallbladder without wall edema or pericholecystic fluid.
The common duct is not dilated measuring 3 mm. Doppler assessment of the main
portal vein shows patency and normal hepatopetal flow.
IMPRESSION:
1. Cholelithiasis without evidence of acute cholecystitis. No bile duct
dilation.
2. Hypoechoic area in the medial right hepatic lobe likely corresponds to
known metastasis, incompletely evaluated. This study does not evaluate for
new liver metastases and if further evaluation is desired, CT or MRI should be
performed.
Radiology Report
MRCP.
HISTORY: ___ man with metastatic colon cancer on chemotherapy, here
with fevers, elevated T bili and alk phos, evaluate for choledocholithiasis.
COMPARISON: Liver ultrasound ___, CT torso ___.
TECHNIQUE: Multiplanar T1- and T2-weighted images were acquired on a 1.5
Tesla magnet, including dynamic 3D imaging, obtained prior to, during, and
after the uneventful intravenous administration of 9 cc of gadolinium-DTPA.
In addition, 2.5 cc of Gadovist with 75 cc of water were given as oral
contrast.
FINDINGS: Again visualized is a large heterogeneous T2 bright mass in the
central right hepatic lobe at the hilum, with peripheral rim hyperenhancement
and central T1 and T2 dark signal, measuring approximately 9.2 x 9.7 x 9.5 cm,
demonstrating interval growth since prior CT torso of ___. Multiple
small satellite nodules are seen adjacent and just superior and lateral to the
dominant mass which appear unchanged. Mild intrahepatic biliary ductal
dilatation which is likely secondary to obstruction from the dominant tumor
mass.
The visualized branches of the portal venous system appear patent. There is
compression of the middle hepatic vein by the large mass, displacing the vein
anteriorly. The right hepatic vein appears to traverse through the mass and
is completely encompassed by it. Patent splenic vein and superior mesenteric
veins. Normal-appearing spleen, pancreas, bilateral adrenal glands.
Bilateral simple-appearing renal cortical cysts as well as large left renal
parapelvic cyst, unchanged. Small subcentimeter periportal lymph nodes.
Cholelithiasis again noted. No evidence of choledocholithiasis. Visualized
small and large bowel unremarkable. No evidence of ascites.
IMPRESSION:
1. Interval growth of large rim-enhancing mass in the liver hilum, with
multiple small satellite nodules, consistent with patient's history of
metastatic colon cancer.
2. Cholelithiasis without evidence of choledocholithiasis.
3. Bilateral simple renal cysts, unchanged.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: FEVER
Diagnosed with DUE TO OTHER VASCULAR DEVICE, IMPLANT, AND GRAFT, ABN REACT-PROCEDURE NEC, MALIGNANT NEOPL RECTUM, HYPERTENSION NOS
temperature: 98.7
heartrate: 82.0
resprate: 16.0
o2sat: 97.0
sbp: 93.0
dbp: 67.0
level of pain: 0
level of acuity: 3.0 | ACTIVE ISSUES:
# FEVER: No definite source found. Patient not neutropenic.
Port suspected due to recent placement, but no growth on
cultures, port did not appear infected. U/a and CXR without
evidence of infection. RUQ ultrasound not consistent with
cholecystitis. No CNS signs/symptoms to indicate neuro process.
Aside from port, no other obvious skin breakdown. Initially
covered with vanc, antibiotics stopped when patient remained
afebrile without source.
# HYPERBILIRUBINEMIA: Tbili and alk phos elevated, possibly
from metastatic burden to liver. RUQ ultrasound showed no signs
of cholecystitis or bile duct obstruction. MRCP was done, which
showed some interval growth of liver mets, but no duct
obstruction. Because of possible implications of
hyperbilirubinemia to future chemo, hepatology was consulted.
They felt that it was unlikely to be due to a side effect of the
chemo due to timing. They also reviewed the MRCP and saw no
blockages that would be amenable to intervention, so most likely
due to metastatic disease.
# PORT FUNCTION: There were issues obtaining blood from
patient's port off and on through his hospitalization. TPA was
used with no improvement. Access needle removed, port care
consulted. Port working well by discharge.
# METASTATIC RECTAL CANCER: Patient currently underoing
treatment with chemo for metastatic colon CA. Last cycle of
FOLFOX on ___. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
pentosan polysulfate sodium / Bactrim / Penicillins / Ativan /
minocycline
Attending: ___.
Chief Complaint:
GI bleed
Major Surgical or Invasive Procedure:
EGD ___
TIPS ___
History of Present Illness:
Ms. ___ is a ___ yo woman with a PMH of alcoholic
cirrhosis c/b esophageal varices (s/p banding x 7, done at ___,
HTN, migraines, arthralgias, asthma/COPD, and folliculitis who
presents to ___ with a massive GI bleed/vomiting blood. Per
husband, she was in her usual state of health and had been sober
for 3 weeks, started drinking yesterday (husband estimates ___
pint vodka). He noticed she was behaving somewhat confused
yesterday, forgetting where she was and/or what she was doing.
Today she complained of feeling cold and had several episodes of
coffee ground and frank hematemesis.
ROS was negative for recent fever, illness, difficulty
breathing, chest pain, abdominal pain, diarrhea, hematochezia or
melena. She had decreased PO over the past 2 days.
***Unclear where she gets her GI care or how she presented***.
Of note, she was evaluated in the ___ clinic in ___ for
self-reported cases of ___ syndrome in the past. She
felt that she was still experiencing lesions from this syndrome
but only had evidence of folliculitis on exam. She left abruptly
before the exam could be finished.
-In the ED, initial vitals: 97.7 140 148/92 16 98% RA
-Labs significant for: H/B ___ (previously 15.7/45.4 in
___, Plt 103, normal electrolytes (K slightly low at 3.5),
ALT/AST 40/150, Tbili 5.2, lipase 80, ethanol level 184, lactate
3.4. UA was bland and blood cx pending.
-On history, she had reportedly been drinking alcohol today and
was confused. She was vomiting blood in the ED. An NG tube was
placed and 1L of blood was suctioned from her stomach. She was
intubated for airway protection. Access was obtained with two 18
and one 20-guage IV. She was not given any antibiotics due to
her reported history of ___ syndrome.
-Hepatology was consulted and planned to perform an EGD.
-She received 1L NS, 2U PRBC's, and IV PPI. She was ordered for
octreotide.
-On transfer, vitals were: 97.7 ___ 22 100% Intubation
On arrival to the MICU, she remained afebrile, was tachycardic
and normotensive, sedated and intubated. GI performed bedside
EGD and identified a small esophageal varix with evidence of
prior bleeding. Variceal banding was attempted but unsuccessful,
and provoked frank bleeding from the varix. The varix was
irrigated and bleeding self-resolved after approximately 15
minutes. Interventional radiology was consulted for TIPS and
diagnostic paracentesis. Patient was brought to ___ suite
approx. 2:00 AM.
Post-EGD she was started on IV ciprofloxacin for SBP concern,
protonix gtt and octreotide gtt. She was sedated on fentanyl and
versed drip upon arrival to the floor; her versed was
discontinued and she was started on propofol. Given her history
of alcohol abuse she was started on phenobarbital protocol.
sign-out with ___: TIPS and paracentesis performed successfully
without complication. Portosystemic pressure 21 --> 11 pre/post
TIPS respectively. normal hepatopedal flow visualized through
the TIPS. No significant varices visualized during procedure.
Performed successful paracentesis and drained approx. 3.5L
ascetic fluid which was sent for labs and cultures.
Review of systems:
+ per HPI, all other ROS negative
Past Medical History:
ALCOHOLIC CIRRHOSIS C/B ESOPHAGEAL VARICES
HYPERTENSION
ASTHMA/COPD
GERD
MIGRAINE HEADACHES
___ SYNDROME (to penicillins)
ARTHRALGIAS
FOLLICULITIS
HIDRADENTIS SUPPURATIVA
ESOPHAGEAL VARICES ___: Banding procedure x 7
OVARIAN CYSTS ___
Social History:
___
Family History:
Mother Living ___ DIABETES MELLITUS
Father Living UNKNOWN
Comments: 2 brothers good health
Physical Exam:
ADMISSION PHYSICAL EXAM
=========================
Vitals: T: 97.7 P: 125 BP: 148/92 R: 22 O2: 100%
GENERAL: sedated, intubated
HEENT: scleral icterus, perrl
NECK: supple, distended EJ
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: no murmurs, rubs, gallops
ABD: Distended, firm. 3cm abrasion to RUQ.
EXT: no pitting edema. Warm, well perfused, 2+ pulses
bilaterally
SKIN: no jaundice
NEURO: sedated
DISCHARGE PHYSICAL EXAM
========================
Vitals: Tm99.3 HR110s BP90s-120s/50s-70s O2 98 RA
GENERAL: lying in bed, NAD.
HEENT: mildly icteric sclerae; dobhoff in place
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: tachycardic; regular rhythm; no appreciable murmurs
ABD: mildly distended, nontender, not tense.
EXT: no edema, warm and well perfused.
SKIN: jaundiced
NEURO: alert, oriented to place, month but does not know year,
no asterixis
Pertinent Results:
ADMISSION LABS
=================
___ 08:15PM BLOOD WBC-8.4 RBC-3.21*# Hgb-11.0*# Hct-33.0*#
MCV-103* MCH-34.3* MCHC-33.3 RDW-18.1* RDWSD-68.9* Plt ___
___ 08:15PM BLOOD ___ PTT-36.0 ___
___ 08:15PM BLOOD Plt ___
___ 08:15PM BLOOD Glucose-116* UreaN-9 Creat-0.5 Na-142
K-3.5 Cl-104 HCO3-24 AnGap-18
___ 08:15PM BLOOD ALT-40 AST-150* AlkPhos-166* TotBili-5.2*
___ 08:15PM BLOOD Albumin-3.0*
___ 06:52AM BLOOD Albumin-2.6* Calcium-7.8* Phos-4.0
Mg-1.3*
___ 08:15PM BLOOD ASA-NEG ___ Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 10:55AM BLOOD Type-ART PEEP-5 FiO2-50 pO2-120* pCO2-31*
pH-7.49* calTCO2-24 Base XS-2 Intubat-INTUBATED
___ 08:33PM BLOOD Lactate-3.4*
MICROBIOLOGY:
Peritoneal fluid and blood cultures negative
IMAGING AND DIAGNOSTICS:
___ EKG
Sinus tachycardia. No previous tracing available for comparison.
___ CXR
IMPRESSION:
Endotracheal tube in satisfactory position.
___ KUB
IMPRESSION:
No definite signs of obstruction.
___ CXR
IMPRESSION:
Compared to prior chest radiographs, ___ and ___.
Substantial increase in opacification in the left lower hemi
thorax is
probably a combination of worsening atelectasis and increasing
moderate left pleural effusion. Heart is top-normal size.
Pulmonary vasculature is mildly engorged but there is no
pulmonary edema or right pleural effusion. No pneumothorax.
Tip of the endotracheal tube at the thoracic inlet is in
standard position, 5.5 cm above the carina. Esophageal drainage
tube passes to the mid portion of a nondistended stomach.
TIPS US ___:
IMPRESSION:
1. Patent TIPS with wall to wall flow and top normal velocities.
2. Very nodular cirrhotic appearing liver. No gross liver lesion
identified.
3. Minimal ascites.
4. Splenomegaly.
5. Cholelithiasis.
DISCHARGE LABS:
=============================
___ 05:40AM BLOOD WBC-4.4 RBC-2.82* Hgb-9.3* Hct-28.7*
MCV-102* MCH-33.0* MCHC-32.4 RDW-18.5* RDWSD-69.2* Plt Ct-59*
___ 03:44AM BLOOD Neuts-59.9 ___ Monos-8.6 Eos-2.8
Baso-0.3 Im ___ AbsNeut-1.96 AbsLymp-0.92* AbsMono-0.28
AbsEos-0.09 AbsBaso-0.01
___ 05:40AM BLOOD ___ PTT-35.4 ___
___ 05:40AM BLOOD Glucose-110* UreaN-7 Creat-0.4 Na-131*
K-3.9 Cl-100 HCO3-22 AnGap-13
___ 05:40AM BLOOD ALT-25 AST-75* AlkPhos-111* TotBili-3.3*
___ 05:40AM BLOOD Albumin-2.9* Calcium-8.3* Phos-3.6 Mg-1.7
___ 05:40AM BLOOD TSH-5.0*
___ 05:45AM BLOOD HAV Ab-POSITIVE
___ 07:00AM BLOOD HBsAg-NEGATIVE HBcAb-NEGATIVE IgM
HBc-NEGATIVE
___ 06:13PM ASCITES WBC-283* RBC-4350* Polys-13* Lymphs-17*
___ Mesothe-4* Macroph-66*
___ 05:08AM ASCITES WBC-87* RBC-2925* Polys-20* Lymphs-18*
___ Mesothe-21* Macroph-41*
___ 05:08AM ASCITES TotPro-0.8 Glucose-123 Creat-0.2
LD(LDH)-49 Amylase-14 TotBili-0.6 Albumin-<1.0
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler ___ PUFF IH Q4H:PRN sob
2. Cyclobenzaprine 20 mg PO HS
3. Gabapentin 800 mg PO QHS
4. Omeprazole 40 mg PO DAILY
5. Propranolol 80 mg PO DAILY
6. TraMADOL (Ultram) 50-100 mg PO Q6H:PRN pain
Discharge Medications:
1. TraMADOL (Ultram) 50 mg PO BID PRN pain
2. Azithromycin 500 mg PO Q24H Duration: 5 Days
RX *azithromycin 500 mg 1 tablet(s) by mouth daily Disp #*3
Tablet Refills:*0
3. Ciprofloxacin 0.3% Ophth Soln 2 DROP RIGHT EAR BID
RX *ciprofloxacin HCl 0.2 % 2 drop otic twice a day Disp #*1
Tube Refills:*0
4. Dexamethasone Ophthalmic Susp 0.1% 4 DROP RIGHT EAR BID
RX *dexamethasone [Maxidex] 0.1 % 1 drop otic twice a day
Refills:*0
5. Furosemide 20 mg PO DAILY
RX *furosemide 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
6. Lactulose 30 mL PO Q6H
RX *lactulose 20 gram/30 mL 30 ml by mouth every six (6) hours
Refills:*0
7. Magnesium Oxide 400 mg PO BID
RX *magnesium oxide 400 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
8. Multivitamins 1 TAB PO DAILY
RX *multivitamin [Daily Multi-Vitamin] 1 tablet(s) by mouth
daily Disp #*30 Tablet Refills:*0
9. Rifaximin 550 mg PO BID
RX *rifaximin [Xifaxan] 550 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
10. Spironolactone 50 mg PO DAILY
RX *spironolactone 50 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
11. Thiamine 500 mg PO DAILY
RX *thiamine HCl (vitamin B1) 500 mg 1 tablet(s) by mouth daily
Disp #*30 Tablet Refills:*0
12. Albuterol Inhaler ___ PUFF IH Q4H:PRN sob
13. Omeprazole 40 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES
Variceal bleed
Alcohol hepatitis
Decompensated EtOH cirrhosis
External otitis media
SECONDARY DIAGNOSES
Alcohol abuse
Discharge Condition:
Mental Status: Clear and coherent. Sometimes confused.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: History: ___ with intubation // assess et tube
TECHNIQUE: Portable chest x-ray.
COMPARISON: None.
FINDINGS:
Lung volumes are somewhat low. The cardiomediastinal silhouette and pulmonary
vasculature are unremarkable. An endotracheal tube terminates approximately 4
cm above the carina. A transesophageal tube is seen coursing out of the field
of view, but the side port overlying the region of the stomach. No definite
focal consolidation is identified. There is mild left basilar atelectasis.
There is no pleural effusion or pneumothorax.
IMPRESSION:
Endotracheal tube in satisfactory position.
Radiology Report
INDICATION: ___ year old woman with massive variceal bleed, hematemesis //
TIPS to be placed
COMPARISON: None available
TECHNIQUE: OPERATORS: Dr. ___, Interventional Radiology Fellow and Dr.
___, attending radiologist performed the procedure. Dr. ___
___ personally supervised the trainee during the key components of the
procedure and has reviewed and agrees with the trainee's findings.
ANESTHESIA: General anesthesia was administered by the anesthesia department.
MEDICATIONS: Please see anesthesia notes. Clindamycin 600 mg
CONTRAST: 85 ml of Optiray contrast.
FLUOROSCOPY TIME AND DOSE: 28.5 min, 904 mGy
PROCEDURE: 1. Paracentesis in the right upper quadrant with placement of a 5
___ flush catheter.
2. Right internal jugular venous access using ultrasound.
3. Pre-procedure right atrial, right hepatic balloon-occluded and portal vein
pressure measurements.
4. CO2 portal venogram in AP and lateral projections.
5. Contrast enhanced portal venogram.
6. Placement of a 10 mm x 8 cm x 2 cm Viatorr covered stent.
7. Post-stenting balloon angioplasty of the TIPS shunt with a 10 mm balloon.
8. Post-stenting portal venogram.
PROCEDURE DETAILS: Following the discussion of the risks, benefits and
alternatives to the procedure, written informed consent was obtained from the
healthcare proxy. The patient was then brought to the angiography suite and
placed supine on the exam table. A pre-procedure time-out was performed per
___ protocol. The neck and abdomen was prepped and draped in the usual
sterile fashion.
Under ultrasound guidance a 19 gauge needle was inserted into the right upper
quadrant peritoneum until there was flow of ascites fluid through the needle.
A ___ wire was advanced through the needle and coiled in the right upper
quadrant. Under fluoroscopic guidance, a 5 ___ straight flush catheter was
advanced over the ___ wire and left in the perihepatic space. The
catheter was then attached to tubing and 3.5 L of straw-colored ascites was
drained.
Under continuous ultrasound guidance, the patent right internal jugular vein
was compressible and accessed using a micropuncture needle. Images of
ultrasound access were stored on PACS. Subsequently a Nitinol wire was passed
into the right atrium using fluoroscopic guidance. A small incision was made
at the needle entry site. The needle was exchanged for a micropuncture sheath.
The Nitinol wire was removed and a ___ wire was advanced distally into
the IVC.
The micropuncture sheath was then removed and a 9 ___ sheath was advanced
over the wire into the inferior vena cava. Using a MPA and a angled glide,
access was obtained in the right hepatic vein. Appropriate position was
confirmed with contrast injection and fluoroscopy in AP and lateral views.
Then a occlusion balloon was advanced over the wire into the distal right
hepatic vein. The wire was then removed and portal pressure measurements were
obtained after balloon occlusion. The pressure measurements were obtained
through the sheath to obtain free hepatic vein pressures. A CO2 portal
venogram was performed in the AP and lateral projections.
Following procedural planning, the Amplatz wire and occlusion balloon were
removed and the TIPS metal cannula was advanced through the sheath. Once the
sheath was placed in an appropriate position, the cannula device was inserted
over the Amplatz wire and the wire was exchanged for ___ needle.
The angled sheath was turned anteriorly. The needle was then advanced through
liver parenchyma and the needle was withdrawn over its sheath. The TIPS sheath
was withdrawn while gentle suction was applied. Upon blood return, a Glidewire
was introduced into the catheter to attempt to pass into the portal vein. The
angled Glidewire was unable to be passed into the main portal vein and
therefore was exchanged for a headliner micro wire. The headliner microwire
was passed into the main portal vein. A micro catheter (renegade ___) was
advanced over the headliner into the main portal vein. The headliner wire was
exchanged for V18 micro wire. The micro catheter was then removed and a 4
___ C2 glide catheter was advanced over the V18 into the splenic vein.
The micro wire was exchanged for an Amplatz wire and extended into the splenic
vein. Attempts to pass a straight flush catheter was unsuccessful through the
liver parenchymal tract. Therefore a 6 mm mustang balloon was advanced over
the Amplatz wire and pre dilation of the liver tract was performed.
Subsequently the straight flush catheter was advanced over the wire and a
contrast enhanced portal venogram was performed. Next direct portal pressure
measurements and right atrial pressure measurements were obtained.
An Amplatz wire was advanced through the straight flush catheter into the
splenic vein. The catheter was removed and a 10 mm x 8 cm x 2 cm Viatorr
covered stent was advanced into appropriate position and deployed. Following
stent deployment, the stent was dilated using a 10 mm balloon.
The straight flush catheter was advanced over the wire and the wire was
removed. Repeat portal and right atrial pressure measurements were performed.
The sheath was then removed from the right internal jugular vein site and
pressure held for 10 minutes to achieve hemostasis. Steri-strips and sterile
dressings were applied.
The patient tolerated the procedure well. There were no immediate
post-procedure complications. The patient was transferred to the PACU in
stable condition.
FINDINGS:
1. Pre-TIPS right atrial pressure of 40 and balloon-occluded portal pressure
measurement of 19 resulting in portosystemic gradient of 21 mmHg.
2. CO2 portal venogram showing normal portal venous anatomy with a favorable
trajectory from the right hepatic vein to the right portal vein.
3. Contrast enhanced portal venogram showing hepatofugal flow towards the
splenic vein. Enlarged coronary vein with retrograde flow into the
gastroesophageal varices.
4. Post-TIPS portal venogram showing restoration of hepatopetal flow with
brisk flow through the TIPS shunt into the right atrium. No filling of the
esophageal varices is identified.
5. Post-TIPS right atrial pressure of 30 and portal pressure of 19 resulting
in portosystemic gradient of 11 mmHg.
6. 3.5 L of straw-colored ascites removed through a peritoneal drain. Sample
sent for culture.
IMPRESSION:
1. Successful right internal jugular access with transjugular intrahepatic
portosystemic shunt placement with decrease in porto-systemic pressure
gradient from 21 to 11 mm Hg.
2. 3.5 liters of ascites drained.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with ett // ett ett
IMPRESSION:
Compared to prior chest radiographs, ___ and ___ one.
Substantial increase in opacification in the left lower hemi thorax is
probably a combination of worsening atelectasis and increasing moderate left
pleural effusion. Heart is top-normal size. Pulmonary vasculature is mildly
engorged but there is no pulmonary edema or right pleural effusion. No
pneumothorax.
Tip of the endotracheal tube at the thoracic inlet is in standard position,
5.5 cm above the carina. Esophageal drainage tube passes to the mid portion
of a nondistended stomach.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with recent NG tube placement // Please check
tube position Please check tube position
IMPRESSION:
Compared to prior chest radiographs ___.
2 successive frontal chest radiographs show advancement of the esophageal
drainage tube, initially looped in the mid esophagus and terminating in the
hypopharynx, to standard position in the mid stomach.
Moderate left pleural effusion has increased substantially since ___.
There is no right pleural effusion and no pneumothorax. Some left lower lobe
atelectasis is presumed.
Radiology Report
INDICATION: ___ year old woman with UGIB, bilious emesis // please evaluate
for obstruction
TECHNIQUE: Single supine view of the abdomen was obtained.
COMPARISON: None available
FINDINGS:
There are no abnormally dilated loops of large or small bowel. A
transesophageal tube is noted, terminating in the stomach.
Free air is difficult to assess on this single supine film.
Osseous structures are unremarkable.
There are no unexplained soft tissue calcifications or radiopaque foreign
bodies.
IMPRESSION:
No definite signs of obstruction.
Radiology Report
EXAMINATION: DUPLEX DOPP ABD/PEL
INDICATION: ___ year old woman with etoh cirrhosis, s/p TIPS ,evaluating tips
// post TIPS ultrasound
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: TIPS procedure ___
FINDINGS:
LIVER: The hepatic parenchyma is coarse and echogenic The contour of the liver
is very nodular. There is no focal liver mass identified. There is mild
ascites predominantly in the perihepatic space.
BILE DUCTS: There is no intrahepatic biliary dilation. The CBD measures 3 mm.
GALLBLADDER: Several small gravel like stones are seen in the neck of the
gallbladder.
PANCREAS: The pancreas is unremarkable but is only minimally visualized due to
overlying bowel gas.
SPLEEN: Normal echogenicity, measuring 16.3 cm.
KIDNEYS: No hydronephrosis on limited views of the kidneys.
DOPPLER EXAMINATION: The main portal vein is patent with hepatopetal flow at
a velocity of 32 cm/sec. The TIPS shunt is patent with wall wall flow and
velocities of 170, 148 and 146 cm/sec in the proximal, mid and distal portions
respectively. Flow within the right and left portal veins is toward the TIPS.
IMPRESSION:
1. Patent TIPS with wall to wall flow and top normal velocities.
2. Very nodular cirrhotic appearing liver. No gross liver lesion identified.
3. Minimal ascites.
4. Splenomegaly.
5. Cholelithiasis.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Hematemesis, Altered mental status
Diagnosed with Hematemesis
temperature: 97.7
heartrate: 140.0
resprate: 16.0
o2sat: 98.0
sbp: 148.0
dbp: 92.0
level of pain: unable
level of acuity: 1.0 | Ms. ___ is a ___ yo woman with a PMH of alcoholic
cirrhosis c/b esophageal varices (s/p banding x 7), HTN,
migraines, arthralgias, and folliculitis who presented to ___
with an esophageal variceal bleed.
#Esophageal variceal bleed: Secondary to portal htn as a result
of cirrhosis. Patient received a total of 2 units of pRBCS. EGD
was attempted but unable to stop bleeding. She was taken for
TIPS by ___ on ___ with concurrent paracentesis (3L). TIPS
reduced pressures from 21 mmHG to 11 mmHG. She was initially
treated with IV PPI and Octreotide gtt. On ___, her
octreotide gtt was discontinued and her PPI was changed to BID
from gtt. IV cipro was given for SBP prophylaxis and she
completed a 7-day course. Her hemoglobin remained stable
throughout the rest of the hospitalization. TIPS ultrasound
___ showed patent flow.
#ETOH hepatitis: Patient was recently drinking about 1 pint per
day, after having been sober for past few weeks. Her labs were
consistent with alcohol hepatitis, DF was ___. Steroids had been
held in the setting of acute UGIB, and then not indicated as
patient was improving witohut them. Nutrition was initially
managed with tubefeeds through an NG tube. Upon discharge, NGT
had been removed and attempt made at placing a dobhoff. Patient
did not tolerate dobhoff secondary to ear pain and gagging. She
was instructed to consume at least 3 ensure or carnation
breakfast supplements daily.
# ETOH cirrhosis c/b varices s/p banding x 7, ascites, HE:
Patient with cirrhosis secondary to alcohol, and does not
regularly see a hepatologist. Her course included a paracentesis
at the same time of TIPS and 3.3, both negative for SBP. She was
started on lasix 20 mg and spironolactone 50 mg daily for volume
overload.
#Confusion/HE: patient presented with altered mental status, in
setting of UGIB, likely hepatic encephalopathy, which worsened
post TIPS. She was started on lactulose and rifaximin and
improved. She was still minimally confused at discharge.
#ETOH withdrawal: S/p phenobarb taper, last dose ___.
#Sinus tachycardia: Patient had sinus tachycardia during
admission to 120s. It was originally felt to be due to alcohol
withdrawal and she was put on phenobarb as above. She continued
to be tachycardic after phenobarb protocol and UOP was decreased
so she was given albumin for volume resuscitation. Her pain was
also addressed post-tips. She remained tachycardic to the 110's
upon discharge. TSH was checked and was 5.
#Right ear pain: patient had right ear pain with some erythema.
She was started on Cipro ear drops BID, dex ear drops and
azithromycin PO (pen anaphylaxis) (day ___ for treatment of
otitis media vs externa. Her symptoms improved after NGT was
removed.
TRANSITIONAL ISSUES
===================== |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Fatigue, Weakness
Major Surgical or Invasive Procedure:
Right heart catheterization ___
Coronary angiography ___
History of Present Illness:
___ year old man with history of coronary artery disease s/p PTCA
LAD in ___, IMI in ___, LAD PCI at the time, BMS (minivision)
in LPDA in ___, ischemic cardiomyopathy (EF 32% in ___ s/p
ICD, and paroxysmal atrial fibrillation on amiodarone, who
presents for fatigue.
Patient was in his USOH and was planned for a R hip replacement
due to femoral loosening of prior THR. He was in fact seen at
___ cardiology pre-operatively and had exercise MIBI that was
notable for partially reversible, small, moderate severity
perfusion defect involving the RCA territory (as well as fixed
large severe perfusion defect involving the LAD territory
consistent with prior MIs). The plan was to follow up in 3
months
rather than planned 6 month follow up given this new finding but
there was no plan for cath prior to that.
He then underwent unremarkable R THR (___, ___ and was
discharged to rehab after 4 day admission. He completed 2 weeks
of rehab and then was at home. He noted at home that he was able
to go up and down stairs of his townhouse normally; however,
sometimes he was SOB with exertion at the top of the stairs.
Occasionally he had "very mild chest pressure, not pain" in the
___ his chest with this SOB. He states this is different
from prior MIs in that that was a/w more pain.
He reported this to his PCP (BWH) and to cards (BI). Given that
he was initially having cough worse while lying flat (+/-
?orthopnea, not clear from the story), PCP initiated on ___
10,
then increased to 20 when he did not derive any significant
benefit. PCP also initiated imdur 30 daily given concern that
there may be anginal component to this. Since patient did not
have any relief, he stopped imdur about 3 days ago. BI cards was
amenable to this plan with the intention of seeing patient in ___
clinic on ___. However, patient reported too significant fatigue
and so presented to ED.
He specifically denies recent fevers, chills, cough, sore
throat,
palpitations, lightheadedness, orthopnea, ___ edema (has some
improving RLE edema after his procedure), chest pain, cold/heat
intolerance.
In the ED initial vitals were: 98.0, 69, 109/55, 16, 98% RA
Exam notable for: AAOX3, NAD, RRR, Very faint bibasilar cackles,
JVP not elevated, no TTP, no peripheral edema. surgical site R,
c/d/i well healing
EKG: per ED, sub mm ST depressions v5, v6 otherwise unchanged
from prior
Labs/studies notable for:
- CXR negative
- trop neg x1
- proBNP: 1454
- WBC 7.1, HGB 9.1, PLT 274
- BMP WNL, Cr 0.7
___ labs: ___ BNP 2332, Hgb 10.3
Patient was given:
___ 14:58 PO Acetaminophen 1000 mg
Past Medical History:
1. CARDIAC RISK FACTORS: (+)Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
-CABG:
-PERCUTANEOUS CORONARY INTERVENTIONS: PTCA to LAD in ___ and
TPA and directional atherectomy to LAD in ___
-PACING/ICD: ___ ___ ___ ___ dual-chamber
ICD placed ___.
.
3. OTHER PAST MEDICAL HISTORY:
- CAD s/p anterior wall MI
- Atrial fibrillation
- Ischemic cardiomyopathy, EF 35%
- CVA ___ with very minor residual short term memory deficit
- TIA ___ during hip surgery
- Prostate CA- radiation tx ___.
Social History:
___
Family History:
Father - MI, CVA. Two sisters - MI s/p CABG.
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
ADMISSION EXAM
==========================
VS: 98.3 110/65 71 18 97 RA
GENERAL: Well developed, well nourished adult man in NAD;
appears
younger than stated age. Oriented x3. Mood, affect appropriate.
HEENT: PERRL, Conjunctiva were pink
NECK: Supple. JVP not seen at 45 degrees
CARDIAC: III/VI systolic murmur heard best at ___, no rubs
or gallops
LUNGS: Faint rales in L base, no rhonchi or wheeze
ABDOMEN: Soft, non-tender, non-distended
EXTREMITIES: 1+ R > L ___ edema
SKIN: No significant skin lesions or rashes.
PULSES: Distal pulses palpable and symmetric.
DISCHARGE EXAM
==========================
VS: 24 HR Data (last updated ___ @ 328)
Temp: 98.1 (Tm 98.6), BP: 106/52 (106-148/51-71), HR: 62
(60-66), RR: 18 (___), O2 sat: 93% (93-97), O2 delivery: RA
GENERAL: alert and interactive, NAD
HEENT: EOMI, MMM, OP clear
NECK: Supple. JVP not seen at 45 degrees
CARDIAC: III/VI systolic murmur heard best at ___, no rubs
or gallops
LUNGS: CTAB, unlabored respirations
ABDOMEN: Soft, non-tender, non-distended
EXTREMITIES: 1+ R > L ___ edema
SKIN: No significant skin lesions or rashes.
PULSES: Distal pulses palpable and symmetric.
Pertinent Results:
ADMISSION LABS
===========================
___ 12:29PM BLOOD WBC-7.1 RBC-3.27* Hgb-9.1* Hct-30.2*
MCV-92 MCH-27.8 MCHC-30.1* RDW-16.4* RDWSD-54.1* Plt ___
___ 12:29PM BLOOD Neuts-74.5* Lymphs-11.1* Monos-10.5
Eos-3.1 Baso-0.1 Im ___ AbsNeut-5.31 AbsLymp-0.79*
AbsMono-0.75 AbsEos-0.22 AbsBaso-0.01
___ 12:29PM BLOOD Glucose-114* UreaN-16 Creat-0.7 Na-140
K-4.3 Cl-100 HCO3-25 AnGap-15
___ 12:29PM BLOOD proBNP-1454*
___ 12:29PM BLOOD cTropnT-<0.01
___ 04:02PM BLOOD cTropnT-<0.01
___ 12:29PM BLOOD TSH-1.9
MICROBIOLOGY
===========================
___ 3:16 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: < 10,000 CFU/mL.
RELEVANT STUDIES
===========================
___ CXR PA/LATERAL:
Comparison to ___. No relevant change is noted.
The lung
volumes are normal. Normal size of the cardiac silhouette.
Normal hilar and mediastinal contours. No evidence of
pneumonia, pulmonary edema or pleural effusions. Mild
elongation of the descending aorta. Left pectoral pacemaker in
situ.
___ RLE U/S: No evidence of deep venous thrombosis in the
right lower extremity veins.
DISCHARGE LABS
===========================
___ 07:40AM BLOOD WBC-6.5 RBC-3.37* Hgb-9.2* Hct-30.8*
MCV-91 MCH-27.3 MCHC-29.9* RDW-16.2* RDWSD-54.2* Plt ___
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Enalapril Maleate 5 mg PO BID
2. Metoprolol Succinate XL 50 mg PO DAILY
3. Amiodarone 200 mg PO DAILY
4. Warfarin 2.5 mg PO DAILY16
5. Atorvastatin 40 mg PO QPM
6. sildenafil 50 mg oral 1X:ASDIR
7. Aspirin 81 mg PO DAILY
8. Furosemide 20 mg PO DAILY
9. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
10. potassium chloride 20 mEq oral DAILY
11. TraMADol 50 mg PO Q8H:PRN Pain - Moderate
Discharge Medications:
1. Warfarin 3 mg PO DAILY16
2. Amiodarone 200 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 40 mg PO QPM
5. Enalapril Maleate 5 mg PO BID
6. Metoprolol Succinate XL 50 mg PO DAILY
7. sildenafil 50 mg oral 1X:ASDIR
8. TraMADol 50 mg PO Q8H:PRN Pain - Moderate
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
Fatigue
Systolic heart failure
Secondary diagnosis:
Atrial fibrillation
Coronary artery disease
Normocytic anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: History: ___ with CAD, ischemic cardiomyopathy, prostate cancer
and CVA presents with fatigue, weakness and cough.// Please assess of
pneumonia vs. pulmonary edema Please assess of pneumonia vs. pulmonary
edema
IMPRESSION:
Comparison to ___. No relevant change is noted. The lung
volumes are normal. Normal size of the cardiac silhouette. Normal hilar and
mediastinal contours. No evidence of pneumonia, pulmonary edema or pleural
effusions. Mild elongation of the descending aorta. Left pectoral pacemaker
in situ.
Radiology Report
EXAMINATION: UNILAT LOWER EXT VEINS RIGHT
INDICATION: ___ year old man with recent R hip replacement and residual RLE
edema; now presenting with increased fatigue and persistent RLE edema; r/o
DVT// R/O DVT
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the right lower extremity veins.
COMPARISON: None.
FINDINGS:
There is normal compressibility, flow, and augmentation of the right common
femoral, femoral, and popliteal veins. Normal color flow and compressibility
are demonstrated in the posterior tibial and peroneal veins.
There is normal respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
No evidence of deep venous thrombosis in the right lower extremity veins.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Fatigue, Weakness
Diagnosed with Dyspnea, unspecified, Chest pain, unspecified, Weakness
temperature: 98.0
heartrate: 69.0
resprate: 16.0
o2sat: 98.0
sbp: 109.0
dbp: 55.0
level of pain: 0
level of acuity: 3.0 | Mr. ___ is a ___ male with ___ CAD s/p PTCA
LAD in ___, IMI in ___, LAD PCI at that time, BMS (minivision)
in LPDA in ___, ischemic cardiomyopathy (EF 32% in ___ s/p
ICD and paroxysmal atrial fibrillation on amiodarone who
presented for fatigue.
# FATIGUE:
Patient presented with fatigue thought to be multifactorial
including deconditioning after recent hip replacement,
dehydration, and symptomatic anemia (baseline Hgb ~10; admission
Hgb ___. Patient was euvolemic on admission with BNP decreased
from recent baseline. TSH was wnl and RLE U/S was negative for
DVT. PE felt to be less likely given not tachycardia and not
hypoxemic and has been on on anticoagulation. ICD was
interrogated and showed no evidence of concerning arrhythmias
which could explain new fatigue. Home Lasix and isosorbide
mononitrate had recently been started prior to admission due to
concern that his fatigue was related to worsening CHF; however,
admission weight was less than previously documented dry weight
and BNP down from prior. TTE showed global left ventricular
systolic function is severely depressed (LVEF 25%) secondary to
akinesis of the interventricular septum and apex, and
hypokinesis of the inferior and
posterior walls. Given uncertainty about etiology for fatigue
and for reduced EF (32->25%), he underwent RHC/angio. Right
heart catheterization showed normal filling pressures (mean PCW
9) making pHTN and volume overload less likely. Coronary
angiography showed mild-moderate CAD (mild moderate diffuse
disease of the LAD and ostial LCx) but no significant
flow-limiting stenosis. No further intervention was performed,
and lasix and isosorbide mononitrate were held. Patient remained
euvolemic and fatigue improved over hospital course. ___
evaluated patient and felt he did not require home ___ at this
time.
# HEMOLYTIC ANEMIA:
Initially felt to be anemia of chronic disease from his multiple
medical problems. Patient had recent surgery and Hgb drop
post-surgery. Iron studies were normal. Hemolysis labs were
significant for low haptoglobin, elevated LDH, and reticulocyte
count > 3%. Coombs test negative making autoimmune hemolytic
anemia less likely. Fibrinogen and platelets wnl making DIC and
TTP less likely. No mechanical valve or AS to explain
intravascular hemolysis. No splenomegaly on exam. No clear
medications or recent infections to explain drug-induced or
infectious etiologies of hemolysis. RBC morphology notable only
for shistocytes and ovalocytes but no clear RBC membrane
defects. Hgb/Hct remained stable throughout admission and he did
not require transfusion. Hemolytic anemia ultimatelyattributed
to possibly prior pRBC transfusion. Per chart review of
Partners' records (PCP), patient had recent work-up for APLS
which was positive for DRRVT; it appears these were ordered by
ortho although details of the work up are limited from outside
record review. He will be discharged with outpatient hematology
follow-up for further evaluation. APLS would not explain his
hemolysis nor did we see evidence of arterial thrombi but this
should be further investigated as outpatient.
# CAD: History of anterior and inferior MIs and prior stenting
(last in ___. Patient continued home aspirin 81 mg PO daily,
enalapril 5 mg PO BID, and atorvastatin 40 mg PO QHS. Coronary
angiography showed mild-moderate CAD with no intervention
indicated.
# HFrEF: Patient has known ischemic CM s/p ICD with NYHA III.
TTE showed decreased EF (32% > 25%) and more hypokinesis. ICD
was evaluated and showed no concerning arrhythmias. Right heart
catheterization showed normal filling pressures and patient was
euvolemic throughout admission. Furosemide and isosorbide
mononitrate had recently been started and was held on discharge
given euvolemia. Patient continued home enalapril, Metoprolol
succinate. Patient will follow-up with outpatient cardiologist.
# ATRIAL FIBRILLATION: History of A. fib on amiodarone,
Metoprolol succinate, and warfarin.
#R femoral loosening: s/p R revision THR on ___ at ___.
Continued Tylenol and tramadol for pain control.
#h/o TIA: (___): continued aspirin, statin
TRANSITIONAL ISSUES
=====================================
Discharge weight: 65 kg (143 lbs)
[ ] Consider starting low dose spironolactone as outpatient. TTE
showed decreased LVEF and increased hypokinesis compared to
prior TTE.
[ ] Consider increasing atorvastatin dose. Patient currently on
40 mg QHS but should be on high intensity statin due to CAD hx.
[ ] Warfarin increased to 3 mg daily from 2.5 mg since INR was
sub-therapeutic during admission. Warfarin managed by Dr.
___ in ___. Patient advised to have INR
checked on ___.
[ ] Repeat DRRVT in 4 weeks. Patient had previous APLS
antibodies measured recently (by ___) with positive DRRVT.
[ ] Patient should have further anemia work-up as outpatient.
Hemolysis labs were concerning for low haptoglobin, high LDH
while total bilirubin was normal. Hgb/Hct remained stable
throughout admission. ___'s test was negative as well. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Penicillins / Tetracycline Analogues / Sulfa (Sulfonamide
Antibiotics) / Ampicillin / Clindamycin / surgical glue
Attending: ___.
Chief Complaint:
Left ankle fracture
Major Surgical or Invasive Procedure:
Left ankle ORIF ___, ___
History of Present Illness:
___ female status post trip and fall with a left
bimalleolar ankle fracture
Past Medical History:
IBS, depression, SI, endometriosis, fibroids
Social History:
___
Family History:
non-contributory
Physical Exam:
LLE:
In short leg splint
Sensation intact over exposed toes
Fires ___ and FHL
Toes warm and well perfused
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. BuPROPion (Sustained Release) 450 mg PO QAM
2. DULoxetine 60 mg PO DAILY
3. ARIPiprazole 7.5 mg PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Aspirin 325 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain
5. Senna 8.6 mg PO BID
6. ARIPiprazole 7.5 mg PO DAILY
7. BuPROPion (Sustained Release) 450 mg PO QAM
8. DULoxetine 60 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Left bimalleolar ankle fracture, right ankle sprain with
avulsion
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: KNEE (AP, LAT AND OBLIQUE) LEFT
INDICATION: History: ___ with mechanical fall and pain in the left lower
extremity// Rule out fracture
TECHNIQUE: Frontal, lateral, and sunrise view radiographs of
COMPARISON: ___ knee radiographs.
FINDINGS:
Left total knee arthroplasty hardware is noted. There is a curvilinear
lucency along the medial femoral condyle separating a curvilinear avulsed bone
flake from femur which is new from ___ radiograph. This corresponds
to the proximal insertion site of the medial collateral ligament. Findings
suggest an avulsion fracture of the medial upper condyle secondary to major
collateral ligament injury. There is no dislocation. There is a small knee
joint effusion. No suspicious lytic or sclerotic lesions are identified.
IMPRESSION:
New curvilinear lucency along the medial femoral condyle is concerning for an
avulsion fracture of the medial femoral condyle with associated medial
collateral ligament injury.
Radiology Report
EXAMINATION: TIB/FIB (AP AND LAT) LEFT
INDICATION: History: ___ with mechanical fall and pain in the left lower
extremity// Rule out fracture
TECHNIQUE: Frontal and lateral view radiographs of the left tibia and fibula.
COMPARISON: Same day foot ankle radiograph.
FINDINGS:
There is an oblique anterolaterally displaced fracture of the left distal
fibula diaphysis and an ___ displaced fracture of left
medial malleolus. The tibiotalar joint is laterally subluxed and 1 cm
widening of the medial tibiotalar joint space is consistent with ligamentous
injury. Swelling of the surrounding soft tissues. Ankle joint effusion also
noted. No suspicious lytic lesion, sclerotic lesion, or periosteal new bone
formation is detected. No soft tissue calcification or radio-opaque foreign
bodies are detected. Limited views of the left knee joint is notable for
total knee arthroplasty.
IMPRESSION:
1. Oblique anterolaterally displaced fracture of the distal fibula diaphysis.
2. ___ displaced fracture of left medial malleolus with
lateral tibiotalar joint subluxation and suspected deltoid ligamentous injury.
Radiology Report
EXAMINATION: FOOT AP,LAT AND OBL LEFT
INDICATION: History: ___ with fall and pain in the left lower extremity//
Rule out fracture
TECHNIQUE: Three views of the left foot
COMPARISON: ___ left foot radiograph.
FINDINGS:
There is a comminuted inferior medially displaced fracture of the medial
malleolus with widening of the medial joint space consistent with deltoid
ligamentous injury. Tibiofibular and talofibular the ligamentous injury are
also suspected. There is marked swelling of the surrounding ankle soft
tissues. Mineralization is normal. There are no erosions.
IMPRESSION:
Acute displaced fracture of the medial malleolus with tibiotalar joint
subluxation and evidence of ligamentous injury. Marked surrounding soft
tissue swelling.
Radiology Report
EXAMINATION: CHEST (PRE-OP AP ONLY)
INDICATION: History: ___ with left lower extremity fracture, preop chest
x-ray// Rule out intrathoracic process
TECHNIQUE: Portable frontal upright chest radiograph
COMPARISON: ___ chest CT
FINDINGS:
The lungs are well aerated. There is no focal consolidation. There is no
pleural effusion or pneumothorax. Cardiac silhouette size is mildly enlarged.
Mediastinal contours are unremarkable. No evidence of pulmonary edema. Lower
cervical fusion hardware is partially visualized.
IMPRESSION:
No evidence of pneumonia.
Radiology Report
EXAMINATION: DX ANKLE AND FOOT; DX KNEE AND TIB/FIB
INDICATION: History: ___ with fracture status post reduction// Postreduction
film Postreduction film
Postreduction film
TECHNIQUE: Four views of the left ankle and foot as well as 6 views of the
left tibia fibula and knee were obtained
COMPARISON: Radiographs performed earlier today
IMPRESSION:
The patient is status post reduction of a displaced medial malleolar fracture
with tibiotalar subluxation and an obliquely oriented fracture of the left
fibular diaphysis. Splint material is present obscuring fine osseous detail.
Re-demonstrated is a displaced fracture of the medial malleolus. There
appears to be continued widening of the medial gutter. A mildly displaced
oblique fracture of the left fibular diaphysis is also noted. The talar dome
appears preserved on these views. A left knee prosthesis is present without
evidence of hardware related complications. There is a fairly linear but
obliquely oriented lucency involving the proximal fibular diaphysis which
could reflect a nondisplaced fracture or nutrient foramen.
Radiology Report
EXAMINATION: ANKLE (AP, MORTISE AND LAT) LEFT
INDICATION: LEFT ANKLE FX.ORIF
COMPARISON: Plain radiograph of the Left foot ___.
FINDINGS:
3 intraoperative fluoroscopic images, demonstrate placement of syndesmotic
screws, tension band wire and percutaneous pins, for fixation of the distal
tibial fractures. There remains a high fibular fracture. Improved alignment.
Total fluoroscopic time 18.1 seconds.
IMPRESSION:
Please refer to operative report.
Radiology Report
INDICATION: ___ year old woman with R ankle pain// ?fx
COMPARISON: Prior from ___
FINDINGS:
AP, lateral, oblique views of the right ankle were provided. There is no
acute fracture or dislocation. A tiny well corticated ossific density
inferior to the lateral malleolus is unchanged from prior and may reflect an
old injury. There is also a tiny ossific density inferior to the medial
malleolus which was not clearly seen on the prior exam and may represent a
tiny avulsion, please correlate clinically. There is a small plantar
calcaneal spur which appears unchanged.
IMPRESSION:
Tiny bony fragment inferior to the medial malleolus, not clearly seen on prior
may represent an acute avulsion. Please correlate for focal pain. Otherwise
no acute findings.
Radiology Report
EXAMINATION: TIB/FIB (AP AND LAT) RIGHT
INDICATION: ___ year old woman with ankle and proximal fibula pain//
?___
TECHNIQUE: Two views right tibia and fibula
COMPARISON: Right ankle radiographs ___
FINDINGS:
No fracture or dislocation seen. No destructive lytic or sclerotic bone
lesions. Small rounded calcification anterior to the mid tibia likely within
the soft tissues may reflect a small phleboliths. Mild degenerative changes
in the right knee.
IMPRESSION:
No acute bony injury seen.
Gender: F
Race: WHITE - OTHER EUROPEAN
Arrive by AMBULANCE
Chief complaint: Ankle pain
Diagnosed with Displaced bimalleolar fracture of left lower leg, init, Fall (on) (from) other stairs and steps, initial encounter
temperature: 98.3
heartrate: 81.0
resprate: 18.0
o2sat: 98.0
sbp: 137.0
dbp: 72.0
level of pain: 8
level of acuity: 3.0 | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a left bimalleolar ankle fracture and was admitted to
the orthopedic surgery service. The patient was taken to the
operating room on ___ for left ankle ORIF which the patient
tolerated well. For full details of the procedure please see the
separately dictated operative report. The patient was taken from
the OR to the PACU in stable condition and after satisfactory
recovery from anesthesia was transferred to the floor. The
patient was initially given IV fluids and IV pain medications,
and progressed to a regular diet and oral medications by POD#1.
The patient was given ___ antibiotics and
anticoagulation per routine. The patient's home medications were
continued throughout this hospitalization. The patient worked
with ___ who determined that discharge to rehab was appropriate.
She was also found to have right ankle pain and ecchymosis, and
an x-ray of the right ankle demonstrated a sprain with a small
avulsion fracture of the medial lateral mall. She may be
weightbearing as tolerated in an ankle stirrup for this injury.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
nonweightbearing in the left lower extremity, and will be
discharged on aspirin 325 mg daily for DVT prophylaxis. The
patient will follow up with Dr. ___ routine. A thorough
discussion was had with the patient regarding the diagnosis and
expected post-discharge course including reasons to call the
office or return to the hospital, and all questions were
answered. The patient was also given written instructions
concerning precautionary instructions and the appropriate
follow-up care. The patient expressed readiness for discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Left Monteggia fracture
Major Surgical or Invasive Procedure:
Left elbow open reduction and internal fixation
History of Present Illness:
___ who was walking her dog today and had dog get tied up around
her causing her to fall to ground and strike left forearm.
Immediate onset of pain and swelling at the elbow. No head
strike
or LOC. No pain elsewhere. Evaluated at OSH, where she was found
to have elbow fracture. Also noted to have some numbness and
tingling in left ___ and ___ digit. The tingling and numb
sensation has completely resolved.
Past Medical History:
HTN
Hep C
Social History:
___
Family History:
NC
Physical Exam:
Exam on admission:
AVSS
Gen: A+Ox3, NAD
LUE:
Significant swelling at the left elbow
No evidence of open fracture
Pain with palpation of the left elbow
+EPL, DIO, FPL
SILT in r/u/m distribution
Radial pulse 2+
No TTP over the left shoulder
Exam on discharge:
AFVSS
NAD, A+Ox3
LUE:
Dressings c/d/i
Orthoplast splint for comfort
Compartments soft and compressible
No pain with passive finger motion
Motor intact EPL, FPL, intrinsics
SILT over M/R/U distributions
WWP fingers, 2+ rad pulse
Pertinent Results:
___ 12:07PM BLOOD WBC-5.6 RBC-3.23* Hgb-10.3* Hct-30.7*
MCV-95 MCH-31.9 MCHC-33.6 RDW-13.2 Plt ___
___ 06:31PM BLOOD Neuts-66.3 ___ Monos-4.6 Eos-1.9
Baso-0.8
___ 12:07PM BLOOD Plt ___
___ 07:01PM BLOOD ___ PTT-29.4 ___
___ 12:07PM BLOOD Glucose-107* UreaN-14 Creat-0.8 Na-141
K-4.7 Cl-106 HCO3-30 AnGap-10
___ 12:07PM BLOOD Calcium-8.8 Phos-3.8 Mg-1.7
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Losartan Potassium 100 mg PO DAILY
2. Hydrochlorothiazide 12.5 mg PO DAILY
Discharge Medications:
1. Outpatient Occupational Therapy
Left upper extremity: Non weight bearing
Full active and passive ROM in LUE, including flexion,
extension, pronation, supination.
Resting orthoplast splint for sleeping and ambulation
2. Acetaminophen 1000 mg PO Q6H:PRN pain
3. Aspirin 325 mg PO DAILY
RX *aspirin 325 mg 1 tablet(s) by mouth once a day Disp #*14
Tablet Refills:*0
4. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*50 Tablet Refills:*0
5. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*80 Tablet Refills:*0
6. Senna 8.6 mg PO BID
RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp
#*50 Tablet Refills:*0
7. Hydrochlorothiazide 12.5 mg PO DAILY
8. Losartan Potassium 100 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Left Monteggia fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PRE-OP AP ONLY)
INDICATION: History: ___ with arm fracture, likely to OR // eval for pre op
TECHNIQUE: Semi-upright AP view of the chest
COMPARISON: ___
FINDINGS:
Heart size is normal. The aorta is unfolded. Mediastinal and hilar contours
are unremarkable. Pulmonary vasculature is normal. Lungs are clear. No pleural
effusion or pneumothorax is present. No acute osseous abnormalities
identified.
IMPRESSION:
No acute cardiopulmonary abnormality.
Radiology Report
EXAMINATION: ELBOW, AP AND LAT VIEWS LEFT IN O.R.
INDICATION: Intraoperative fluoroscopy
TECHNIQUE: ELBOW, AP AND LAT VIEWS LEFT IN O.R.
COMPARISON: ___
IMPRESSION:
3 spot fluoroscopy images obtained during open reduction and internal fixation
of the left elbow will bronchial review. Total fluoroscopy time 4.6 seconds
was recorded. For pre size details please review procedure report
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: s/p Fall, LEFT ARM FX
Diagnosed with FX UP RADIUS W ULNA-CLOS, FALL RESULTING IN STRIKING AGAINST OTHER OBJECT, ACTIVITIES INVOLVING WALKING AN ANIMAL, HYPERTENSION NOS
temperature: 98.0
heartrate: 64.0
resprate: 18.0
o2sat: 99.0
sbp: 167.0
dbp: 87.0
level of pain: 9
level of acuity: 3.0 | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a left Monteggia-type elbow fracture and was admitted to
the orthopedic surgery service. The patient was taken to the
operating room on ___ for open reduction and internal
fixation, which the patient tolerated well (for full details
please see the separately dictated operative report). The
patient was taken from the OR to the PACU in stable condition
and after recovery from anesthesia was transferred to the floor.
The patient was initially given IV fluids and IV pain
medications, and progressed to a regular diet and oral
medications by POD#1. The patient was given perioperative
antibiotics and anticoagulation per routine. The patients home
medications were continued throughout this hospitalization. The
patient worked with ___ who determined that discharge to home was
appropriate. The ___ hospital course was otherwise
unremarkable.
At the time of discharge the patient was afebrile with stable
vital signs that were within normal limits, pain was well
controlled with oral medications, incisions were
clean/dry/intact, and the patient was voiding/moving bowels
spontaneously. The patient is nonweight bearing in the left
upper extremity, with full ROM passively and actively at the
elbow, and will be discharged on aspirin for DVT prophylaxis.
The patient will follow up in two weeks per routine. A thorough
discussion was had with the patient regarding the diagnosis and
expected post-discharge course, and all questions were answered
prior to discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Right Distal Femur Fx, Right Tib Plateau Fx, L Cuboid Fx
Major Surgical or Invasive Procedure:
___ - R knee I&D
History of Present Illness:
___ s/p helmeted motorcycle collision. No LOC. On presentation
GCS 15, HD stable, FAST neg. Found to have left foot cuboid
fracture and right knee wound. Patient also reports mild to
moderate pain in left shoulder.
Patient denies numbness, paresthesias and pain in other
extremities.
Past Medical History:
Denies
Social History:
___
Family History:
NC
Physical Exam:
Gen: NAD
MSK:
RLE: Incisions c/d/i, drain in place w/ SS output. SILT
s/s/sp/dp/t Fires ___, FHL, G/S, TA, 1+ DP
LLE: splint in place c/d/i, SILT over distal toes, wiggles toes,
toes wwp
Medications on Admission:
Denies
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Docusate Sodium 100 mg PO BID
3. Multivitamins 1 TAB PO DAILY
4. Senna 17.2 mg PO BID
5. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain
RX *oxycodone 5 mg ___ tablet(s) by mouth q4h prn Disp #*60
Tablet Refills:*0
6. Aspirin 325 mg PO DAILY
RX *aspirin 325 mg 1 tablet(s) by mouth once a day Disp #*28
Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Right Distal Femur Fracture, Right Tibial Plateau Fracture, L
Cuboid Fracture
Discharge Condition:
Stable
Followup Instructions:
___
Radiology Report
INDICATION: ___ year old man with right knee laceration. Found small piece of
bone upon exploration. ? from patella or from other source. // Eval for open
joint fracture
TECHNIQUE: Axial CT images of the right knee were obtained without
intravenous contrast. Coronal and sagittal reformats were generated.
DOSE: Acquisition sequence:
1) Spiral Acquisition 11.5 s, 24.5 cm; CTDIvol = 20.2 mGy (Body) DLP =
494.4 mGy-cm.
Total DLP (Body) = 494 mGy-cm.
COMPARISON: None available
FINDINGS:
There is a comminuted nondisplaced impaction fracture of the lateral femoral
condyle anterolaterally. Intra-articular extension is appreciated.
There is a comminuted minimally displaced intra-articular fracture of the
lateral tibial plateau posteriorly without significant depression. The
fracture line extends into the lateral tibial spine.
No patellar fracture is identified.
There is a small lipohemarthrosis with locules of air within the joint.
Laceration is seen just superior to the patella within the subcutaneous
tissues.
Soft tissue swelling is noted anteriorly.
IMPRESSION:
1. Comminuted nondisplaced impaction fracture of the lateral femoral condyle.
2. Comminuted intra-articular nondepressed fracture of the lateral tibial
plateau posteriorly.
Should there be concern for ligamentous injury, MRI can be performed.
Radiology Report
EXAMINATION: CT T-SPINE W/O CONTRAST Q321 CT SPINE
INDICATION: ___ year old man with neck pain s/p MCC w/ numbness // eval for
vert fracture eval for vert fracture
TECHNIQUE: Non-contrast helical multidetector CT was performed. Soft tissue
and bone algorithm images were generated. Coronal and sagittal reformations
were then constructed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 12.3 s, 48.1 cm; CTDIvol = 32.7 mGy (Body) DLP =
1,572.6 mGy-cm.
Total DLP (Body) = 1,573 mGy-cm.
COMPARISON: CT abdomen and pelvis: ___.
FINDINGS:
Alignment is normal. No fractures are identified. There is no evidence of
critical spinal canal or neural foraminal stenosis. There is no prevertebral
soft tissue swelling. There is no evidence of infection or neoplasm. Mild,
multilevel degenerative changes are noted throughout the thoracic spine,
including anterior posterior osteophytosis.
The imaged portion of the lungs and retroperitoneum is unremarkable.
IMPRESSION:
No evidence of thoracic spine fracture or traumatic malalignment.
Radiology Report
EXAMINATION: MRI CERVICAL, THORACIC, AND LUMBAR
INDICATION: ___ year old man with numbness in ___ like distribution of upper
chest and shoulders status post motorcycle accident// eval for spinal cord
injury, hematoma, central cord syndrome
TECHNIQUE: Sagittal T2, sagittal STIR, and sagittal T1 weighted sequences of
the cervical, thoracic, and lumbar spine were obtained. The examination was
prematurely terminated at the patient's request due to claustrophobia.
COMPARISON: CT thoracic spine ___
CT abdomen and pelvis ___
CT cervical spine ___
FINDINGS:
CERVICAL:
The alignment of the cervical spine is normal. The bone marrow is normal
without evidence of edema or fractures. The height of the vertebral bodies
are maintained. The spinal cord is normal in signal and caliber. No fluid
collections or masses are identified. There is minimal edema anterior to the
C3, C4, and C5 vertebral bodies. There is no spinal canal stenosis.
THORACIC:
The alignment of the thoracic spine is normal. There is linear T1 hypointense
and T2/STIR hyperintense signal along the superior endplate of the T6
vertebral body. There is no marrow edema in the posterior elements. A T1/T2
hyperintense and heterogeneously STIR hyperintense lesion in the T11 vertebral
body, measuring 1.4 cm, likely represents an intraosseous hemangioma. The
vertebral bodies are maintained in height. Schmorl's nodes are scattered
throughout the thoracic spine. The spinal cord is normal in signal and
caliber. No fluid collections or masses are identified.
LUMBAR:
The alignment of the lumbar spine is normal. There is T1 hypointense and
T2/STIR hyperintense signal along the right posterior and superior endplate of
the L5 vertebral body and minimal T1 hypointense and T2/STIR hyperintense
signal along the right inferior endplate of the L4 vertebral body. The
height of the vertebral bodies are maintained. The conus medullaris
terminates at T12-L1. The spinal cord is normal in signal. No fluid
collections or masses are identified.
At T12-L1 through L3-L4, there is no spinal canal or neural foraminal
stenosis.
At L4-L5, disc bulge and facet joint hypertrophy cause mild-to-moderate left
neural foraminal stenosis.
At L5-S1, bulge causes mild bilateral neural foraminal stenosis, right greater
than left.
IMPRESSION:
1. Incomplete examination due to lack patient cooperation.
2. Acute, nondisplaced fracture through the superior endplate of the T6
vertebral body.
3. Minimal prevertebral edema anterior to the C3, C4, and C5 vertebral bodies,
suggestive of anterior longitudinal ligamentous sprain.
4. Edema of the L4-L5 endplates likely represent degenerative changes rather
than traumatic injury.
5. No epidural fluid collections.
6. Normal signal and caliber of the spinal cord.
7. Mild degenerative changes of the cervical, thoracic, and lumbar spine
without evidence of spinal canal or neural foraminal stenosis.
NOTIFICATION: The findings were discussed with Dr. ___. by ___,
M.D. on the telephone on ___ at 9:25 AM, 10 minutes after discovery of
the findings.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Motorcycle accident
Diagnosed with Nondisp unsp condyle fx low end r femr, 7thB, Displaced bicondylar fracture of right tibia, init, Disp fx of cuboid bone of left foot, init for clos fx, Mtrcy driver injured pick-up truck, pk-up/van in traf, init
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: Critical
level of acuity: 1.0 | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a R knee traumatic arthrotomy, Right Distal Femur Fx,
Right Tib Plateau Fx, L Cuboid Fx, and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for a R knee I&D, which the patient
tolerated well. For full details of the procedure please see the
separately dictated operative report. The patient was taken from
the OR to the PACU in stable condition and after satisfactory
recovery from anesthesia was transferred to the floor. The
patient was initially given IV fluids and IV pain medications,
and progressed to a regular diet and oral medications by POD#1.
The patient was given ___ antibiotics and
anticoagulation per routine. The patient's home medications were
continued throughout this hospitalization. The patient worked
with ___ who determined that discharge to home with services was
appropriate. The ___ hospital course was otherwise
unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
WBAT in the RLE and NWB on the LLE , and will be discharged on
ASA 325mg for DVT prophylaxis. The patient will follow up with
Dr. ___ routine. A thorough discussion was had with
the patient regarding the diagnosis and expected post-discharge
course including reasons to call the office or return to the
hospital, and all questions were answered. The patient was also
given written instructions concerning precautionary instructions
and the appropriate follow-up care. The patient expressed
readiness for discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Altered Mental Status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with recent traumatic SDH, had been admitted to neurosurg
here. He was discharged from here to ___, and then
after completing rehab there, transferred today to ___
___. There he was physically aggressive and agitated.
The ___ called EMS to request xfer back to rehab, but EMS took
him to ___ instead. He had labs drawn there (in Careweb and
on chart) and a head CT and the case was d/w Dr. ___ did
not think his agitation related to his head bleed or
hydrocephalus and was concerned about a medical cause of his
delirium. the pt was given Zyprexa 5 and Ativan 2 and then
transferred here. Apparently patient was combative and tried to
punch a nurse at ___ but is calm and cooperative at this time
and has showed no signs of agitation in the ___.
In the ___, initial VS were: 97.6 72 160/81 16 96%. UA
consistent with UTI and he was started on CTX.
On arrival to the floor, he is somnolent but arousable. He does
not follow commands. He withdraws to pain and arouses to noxious
stimuli.
Past Medical History:
TBI from a motrocycle accident many years ago
___
HTN
Social History:
___
Family History:
NA
Physical Exam:
ADMISSION EXAM:
97.9 146/86 80 99%RA FSBG 108
GENERAL - Somnolent man awakes to noxious stimuli
HEENT - NC/AT, dry MM. PEERL pupils 4mm and reactive
NECK - supple
LUNGS - CTA bilat
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS NT ND
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
Neuro: AAOX0. Withdraws to pain and awakens to noxious stimuli
DISCHARGE EXAM:
VS: Tc 97.6 137/77 68 18 100% RA
GENERAL - awake, alert, oriented to person and date, not
oriented to place
HEENT - NC/AT, MMM. PEERL, EOMI, oral mucosa moist, without
lesions
NECK - Supple
LUNGS - CTA bilat, no wheezing/rales/rhonchi
HEART - RRR, no MRG, nl S1-S2
ABDOMEN - +BS/Soft/NT/ND, no r/g
EXTREMITIES - WWP, no c/c/e
NEURO: Left mouth droop with slurred speech (unchanged). He had
___ strength in upper and lower exermities. dysarthric with left
facial droop (unchanged)
Pertinent Results:
ADMISSION LABS
___ 08:10AM BLOOD WBC-6.9 RBC-4.30* Hgb-11.8* Hct-37.4*
MCV-87 MCH-27.5 MCHC-31.6 RDW-14.3 Plt ___
___ 07:30PM BLOOD WBC-7.6 RBC-4.48* Hgb-12.2* Hct-38.6*
MCV-86 MCH-27.4 MCHC-31.7 RDW-14.5 Plt ___
___ 07:20AM BLOOD Glucose-86 UreaN-15 Creat-0.6 Na-140
K-4.0 Cl-102 HCO3-28 AnGap-14
___ 07:30PM BLOOD Glucose-114* UreaN-13 Creat-0.7 Na-143
K-4.3 Cl-101 HCO3-31 AnGap-15
___ 01:03AM BLOOD TSH-1.1
___ 01:07AM BLOOD Type-ART pO2-94 pCO2-45 pH-7.44
calTCO2-32* Base XS-5
___ 10:30PM URINE Blood-SM Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-LG
___ 03:16PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-LG
___ 10:30PM URINE RBC-14* WBC->182* Bacteri-MOD Yeast-NONE
Epi-0
___ 03:16PM URINE RBC-2 WBC-4 Bacteri-NONE Yeast-NONE Epi-0
___ 10:30 pm URINE TAKEN FROM 1902S.
MOST RECENT LABS AT DISCHARGE
___ 09:15AM BLOOD WBC-6.5 RBC-4.65 Hgb-12.8* Hct-40.4
MCV-87 MCH-27.5 MCHC-31.7 RDW-14.0 Plt ___
___ 09:15AM BLOOD Plt ___
___ 09:15AM BLOOD Glucose-91 UreaN-16 Creat-0.6 Na-142
K-4.0 Cl-102 HCO3-28 AnGap-16
___ 09:15AM BLOOD Calcium-9.6 Phos-3.6 Mg-2.1
MICRO
**FINAL REPORT ___
URINE CULTURE (Final ___:
PSEUDOMONAS AERUGINOSA. 10,000-100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- 2 S
CEFTAZIDIME----------- 4 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM------------- 8 R
PIPERACILLIN/TAZO----- 8 S
TOBRAMYCIN------------ <=1 S
___ 3:16 pm URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
___ 11:54 am URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
___:
CT Head:
1 resolution of subdural hematoma and evolution in the right
parietal epidural hematoma which has decreased in size and is
now hypotense and 12 mm thickness. 2 interval development of
ventriculomegaly indicating communicating hydrocephalus. Number
3 resolution of prior hemorrhagic contusions with hypodensities
indicative of encephalomalacia in both frontal regions.
___ 9:05 ___ CT HEAD W/O CONTRAST
IMPRESSION:
1. Little overall change in comparison to prior study from
___ right parietal epidural hematoma which is
minimally decreased in size andnow measures 9 mm from the inner
table of the skull.
2. Again noted is ventriculomegaly indicating communicating
hydrocephalus.
3. Again noted is a right parietal comminuted fracture
extending into
bilateral occipital and right temporal bones.
___:
CT head:
IMPRESSION:
1. Decreased size of right parietal epidural hematoma.
2. Minimal interval worsening of hydrocephalus.
3. Evolving contusion in the right inferior frontal lobe
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Enalapril Maleate 10 mg PO DAILY
2. Aspirin 325 mg PO DAILY
3. LeVETiracetam 1000 mg PO BID
4. traZODONE 25 mg PO HS
5. Aripiprazole 10 mg PO DAILY
Please give at 2pm
6. Quetiapine Fumarate 50 mg PO QHS
7. BusPIRone 20 mg PO TID
8. Ranitidine 150 mg PO BID
9. Phenazopyridine 200 mg PO TID Duration: 3 Days
10. Multivitamins 1 TAB PO DAILY
11. Quetiapine Fumarate 25 mg PO DAILY
At 4PM
12. Acetaminophen 325-650 mg PO Q6H:PRN pain
Discharge Medications:
1. Aspirin 325 mg PO DAILY
2. BusPIRone 20 mg PO TID
3. LeVETiracetam 1000 mg PO BID
4. Multivitamins 1 TAB PO DAILY
5. Ranitidine 150 mg PO BID
6. traZODONE 25 mg PO HS
7. OLANZapine 5 mg PO BID
8. OLANZapine (Disintegrating Tablet) 2.5 mg PO BID:PRN
aggitation
9. Acetaminophen 325-650 mg PO Q6H:PRN pain
10. Enalapril Maleate 20 mg PO DAILY
11. OLANZapine 2.5 mg PO QPM
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Urinary Tract Infection
Altered Mental Status
Delirium
Discharge Condition:
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Mental Status: Confused - sometimes.
Followup Instructions:
___
Radiology Report
INDICATION: New altered mental status and agitation.
COMPARISONS: Chest radiograph ___. CT chest ___.
FINDINGS: The lung volumes are low, which somewhat limits the evaluation.
Within the limitations, there is no consolidation or edema. There is no
pleural effusion or pneumothorax. The mediastinal contours are normal. The
heart size is at the upper limits of normal, and stable from the prior exam.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
HISTORY: History of subdural hemorrhage and hydrocephalus status post fall
today with new altered mental status.
TECHNIQUE: Contiguous axial images were obtained through the brain without
intravenous contrast. Multiplanar reformatted images were prepared and
reviewed.
COMPARISON: Multiple prior CT head scans from ___ to ___.
PROCEDURE:
FINDINGS:
Overall, there is little interval change in comparison to the prior study from
___. Again visualized is a right parietal epidural hematoma
measuring 9 mm from the inner table of the skull, slightly decreased in
comparison to prior study when it measured 11 mm. There is no evidence of new
hemorrhage, edema, large vessel territorial infarction or shift of midline
structures. Areas of encephalomalacia are again noted in bilateral frontal
lobes. The ventricles are large including temporal horns and ___ and ___
ventricles again suggestive of communicating hydrocephalus.
Again noted is a comminuted right parietal bone fracture extending into
bilateral occipital bones and into the right temporal bone; better delineated
on dedicated CT facial from ___. Mucosal thickening is again
noted throughout the ethmoid air cells and the left maxillary sinus with a
mucous retention cyst. The remainder of the visualized paranasal sinuses and
mastoid air cells are clear.
IMPRESSION:
1. Little overall change in comparison to prior study from ___
with right parietal epidural hematoma which is minimally decreased in size and
now measures 9 mm from the inner table of the skull.
2. Again noted is ventriculomegaly indicating communicating hydrocephalus.
3. Again noted is a right parietal comminuted fracture extending into
bilateral occipital and right temporal bones.
Radiology Report
HISTORY: Recent traumatic epidural hematoma and hydrocephalus. Evaluate for
change in hydrocephalus and hematoma.
TECHNIQUE: MDCT acquired contiguous axial images were obtained through the
head without contrast. Coronal and sagittal reformats reviewed.
COMPARISON: CT from ___.
FINDINGS:
There is minimally edema in the right inferior frontal lobe, likely
representing an evolving contusion (2:14). The right parieto-occipital
epidural hematoma has significantly decreased in size, with a maximal width of
4 mm, compared to 9 mm on the last study. The ventricular size has slightly
increased from the prior study, particularly noticeable in the occipital horn
of the right lateral ventricle. There is no new hemorrhage. There is no
significant shift in midline structures. The comminuted fracture of the right
parietal, occipital and temporal bones is unchanged. The mastoid air cells
and middle ear cavities are clear.
IMPRESSION:
1. Decreased size of right parietal epidural hematoma.
2. Minimal interval worsening of hydrocephalus.
3. Evolving contusion in the right inferior frontal lobe.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: NEURO EVAL
Diagnosed with URIN TRACT INFECTION NOS, HYPERTENSION NOS
temperature: 97.6
heartrate: 72.0
resprate: 16.0
o2sat: 96.0
sbp: 160.0
dbp: 81.0
level of pain: 0
level of acuity: 2.0 | ___ y/o male with remote history of TBI, recent head bleed and
hydrocephalous presented with AMS, found to have UTI.
# AMS/Somnolence: The patient was seen in the ___ by neurosurgery
over concern that this was due to progression from his recent
SDH. Neurosurgery did not feel this was secondary to his
neurosurgical issues, and no intervention was needed. He was
initially somnolent and had periods of agitation. He was seen by
psychiatry while in the hospital for psychiatric medication
management. He was treated for a presumed UTI (see below) with
some improvement in his mental status. A TSH was checked to r/o
myxedema as an etiology of his AMS and somnolence and this was
within the normal range. His medications were changed per
psychiatry recommendations (please see attached list). His
mental status still waxed and waned, particularly worse in the
evening time. Patient also with periods of agitation and
aggression likely a component of frontal dementia. This was well
controlled with olanzapine 5mg BID (QAM and QHS) standing and
zydis 2.5mg QPM standing. Repeat CT head on ___ showed mildly
worsened hydrocephalus, improved subdural hematoma.
Neurosurgery team reviewed imaging and determined no
interventions at this time. Plan to follow up in clinic with
neurosurgery with repeat CT head in 2 weeks.
# UTI: Initially the patient had a positive U/A and was treated
with ceftriaxone. The culture grew out pseudomonas that was
resistant to ciprofloxacin, however the quantity of the growth
made contamination possible. Patient was treated pseudomonal UTI
with cefepime for total 7 day course. Repeat urine culture and
U/A were negative. During the entirety of this hospitalization
the patient was afebrile with a normal WBC count.
# HTN: Enalapril was uptitrated from 10mg to 20mg daily. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Motrin / aspirin / shrimp
Attending: ___.
Chief Complaint:
Difficulty Urinating
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with h/o HTN, HLD, T2DM, EtOH cirrhosis, CAD, HFrEF (LVEF
20%), prior PE no longer on anticoagulation presented to the ED
___ for difficulty urinating.
Per history obtained in ED, She was seen by her PCP ___ for
decreased urination over the past ___ days so her daughter
reportedly "doubled up her diuretics." The daughter at bedside
notes that she took double only her torsemide for two days, and
denies taking any additional other medication. During that
appointment she had HR 84. Today she was complaining of fullness
in her lower abdomen, so her daughter brought her to the ED. She
denies any associated chest pain, shortness of breath, abdominal
pain but does note palpitations that "just started." She was
triggered in the ED on ___ for bradycardia (HR ___ that
spontaneously resolved with no further episodes on telemetry. No
episodes of brady in ED since triage.
- In the ED, initial vitals were: 99.3 | 38 | 135/80 | 16, 98%
RA
- Exam was notable for:
General- NAD
HEENT- PERRL, EOMI, normal oropharynx
Lungs- Non-labored breathing, CTAB
CV- RRR, no murmurs, normal S1, S2, no S3/S4
Abd- Soft, nontender, nondistended, no guarding, rebound or
masses
Msk- No spine tenderness, moving all 4 extremities
Neuro-A&O x3, CN ___ intact, normal strength and sensation in
all extremities, normal speech and gait.
Ext- No edema, cyanosis, or clubbing
- Labs were notable for:
proBNP: ___, trop negative x 2.
Lactate: 3.2 -> ___ s/p 1L IVF
SCr: 2.2 -> 1.9 (Baseline 1.5 ___.
Hgb: 10.8
Plt: 56
Mg2+: 1.3 -> 2.4
Phos: 2.5 -> 3.5
- Studies were notable for:
CXR: No acute cardiopulmonary process. No pulmonary edema.
- The patient was given:
___ 03:24 SC Insulin 10 UNIT
___ 04:00 IVF LR 500 mL
___ 06:58 IV Magnesium Sulfate 4 gm
___ 09:31 SC Insulin 4 Units
___ 09:31 PO/NG PARoxetine 40 mg
___ 09:31 PO/NG FoLIC Acid 1 mg
___ 09:31 PO Pantoprazole 40 mg
___ 10:23 PO/NG Cyanocobalamin 500 mcg
___ 14:26 SC Insulin 6 Units
___ 19:04 SC Insulin 6 UNIT
___ 19:04 SC Insulin 6 Units
___ 19:05 IVF NS 500 mL
On arrival to the floor, patient endorses HPI as above. Says she
has not been having anymore difficulty urinating. Denies any
dysuria, suprapubic pain, flank pain. Says she will
intermittently feel palpitations, denies any associated
dizziness/lightheadedness, cp, SOB. Denies any orthopnea or
increased ___ edema.
Past Medical History:
- Alcoholic cirrhosis c/b medium esophageal varices
- Alcohol use disorder in remission - last drink was around ___
- Non-ischemic cardiomyopathy - likely related to alcohol - LVEF
17% in ___ (OSH; nuclear stress negative), 40-45% in ___, 20%
in ___.
- Diabetes II
- Hypertension
- Dyslipidemia
- Anemia of Chronic Disease + Iron Deficiency
- Prior history of GI bleeds
- Asthma - no h/o hospitalizations, steroids, intubation
- Depression
- GERD
- Macular degeneration
- Osteoarthritis
- s/p TAH
Social History:
___
Family History:
Father died of CHF exacerbation in mid-___.
Mother alive and no cardiac history.
2 kids alive and well.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VITALS: 97.7 | 145/78 | 87 | 21, 99% Ra
GENERAL: WDWN elderly woman, NAD.
HEENT: PERRL, EOMI. Sclera anicteric and without injection. MMM.
NECK: JVP 10cm.
CARDIAC: RRR. Audible S1 and S2. No murmurs/rubs/gallops.
LUNGS: CTAB. No wheezes, rhonchi or rales. No increased work of
breathing.
ABDOMEN: S, ND, NT, BS+
EXTREMITIES: WWP. No clubbing, cyanosis. Trace ___ edema b/l.
Pulses DP/Radial 2+ bilaterally.
NEUROLOGIC: AOx3. CN2-12 grossly intact. Moving all 4 limbs
spontaneously.
DISCHARGE PHYSICAL EXAM:
========================
___ 0654 Temp: 98.7 PO BP: 123/73 R Lying HR: 75 RR: 18 O2
sat: 97% O2 delivery: Ra O2 sat: 96% O2 delivery: Ra
General- NAD
HEENT- EOMI, normal oropharynx
Lungs- Non-labored breathing, CTAB
CV- RRR, no murmurs, normal S1, S2, no S3/S4
Abd- Soft, nontender, nondistended, no guarding, rebound or
masses
Msk- No spine tenderness, moving all 4 extremities with purpose
Neuro-A&O x3, normal strength and sensation in all extremities,
normal speech and gait.
Ext- trace pitting edema of the BLE; distal pulses intact
Pertinent Results:
ADMISSION LABS:
===============
___ 11:54PM BLOOD WBC-4.7 RBC-3.94 Hgb-10.8* Hct-34.9
MCV-89 MCH-27.4 MCHC-30.9* RDW-17.1* RDWSD-53.8* Plt Ct-56*
___ 11:54PM BLOOD ___ PTT-26.4 ___
___ 11:54PM BLOOD Glucose-229* UreaN-53* Creat-2.2* Na-142
K-4.0 Cl-104 HCO3-23 AnGap-15
___ 11:54PM BLOOD ___ 11:54PM BLOOD Calcium-8.8 Phos-2.5* Mg-1.3*
___ 12:02AM BLOOD Lactate-3.2* K-3.8
MICRO:
======
___ Urine Culture: No growth
___ Blood Culture x2: No growth
IMAGING:
========
___ CXR FINDINGS:
No acute cardiopulmonary process.
DISCHARGE LABS:
==============
___ 05:44AM BLOOD WBC-4.5 RBC-3.61* Hgb-9.9* Hct-32.4*
MCV-90 MCH-27.4 MCHC-30.6* RDW-17.2* RDWSD-57.0* Plt Ct-41*
___ 05:44AM BLOOD Glucose-167* UreaN-31* Creat-1.2* Na-143
K-3.7 Cl-105 HCO3-25 AnGap-13
___ 05:44AM BLOOD Calcium-8.3* Phos-2.7 Mg-1.7
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: Scratch ___ with palpitations// Palpitations
TECHNIQUE: Chest AP
COMPARISON: Chest radiograph dated ___
FINDINGS:
Lung volumes are low. There is mild cardiomegaly, unchanged. There is no
definite focal consolidation to suggest pneumonia. No pneumothorax or large
pleural effusion. No pulmonary edema. There are chronic posterior rib
fractures bilaterally.
IMPRESSION:
No acute cardiopulmonary process.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Bradycardia, Dysuria
Diagnosed with Acute kidney failure, unspecified
temperature: 99.3
heartrate: 38.0
resprate: 16.0
o2sat: 98.0
sbp: 135.0
dbp: 80.0
level of pain: 0
level of acuity: 1.0 | Ms. ___ is a ___ with a history of HTN, HLD, T2DM, EtOH
cirrhosis, CAD, CHF, prior PE no longer on anticoagulation who
presented to the ED on ___ for difficulty urinating, found to
have ___ felt to be secondary to overall volume depletion after
taking double of her home diuretic dose. She was given IV fluids
and her ___ resolved, and she was on her home medications at the
time of discharge. She also had orthostatic hypotension with
reports of falling at home. Orthostasis resolved by discharge.
Due to concern for mild cognitive impairment and reported falls,
her daughter will stay with her after discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Toradol / Tequin / Rocephin / vancomycin / amoxicillin /
Penicillins / Iodinated Contrast Media - IV Dye
Attending: ___
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old Female presents with chest pain and dyspnea after
taking a ___ train trip the week prior to admission.
She was coming to ___ for the funeral of her daughter who
committed suicide 1 week prior. She states that 4 days prior to
presentation she had exertional left chest pain radiating to her
scapula, and notes that the pain is ___ and sharp in nature.
She does have a history of DVT and PE, although was not on
anticoagulation. She states her Left leg was swollen since the
trip. She has had a cough, but no hemoptysis.
The patient is apparently allergic to iodine. In addition to the
chest pain, she also notes 5 episodes of melena on the day of
presentation and multiple episodes of bilious vomiting.
In the ED her initial vitals were 96.2, ___, 16,
100%RA. She was given 2L of IV fluids, Morphine,
diphenhydramine, dilaudid and metoclopramide.
Past Medical History:
DVT/PE
Ovarian Cancer s/p TAHBSO
Right Heart Failure
Supraventricular Tachycardia (has loop recorder in) s/p Ablation
ECT
PTSD
Social History:
___
Family History:
Mother: CAD
Father: HTN
Daughter: Died of ___
Brother: COPD
Uncle: SVT
Physical Exam:
ROS:
GEN: - fevers, - Chills, - Weight Loss
EYES: - Photophobia, - Visual Changes
HEENT: - Oral/Gum bleeding
CARDIAC: + Chest Pain, - Palpitations, - Edema
GI: - Nausea, - Vomitting, - Diarhea, - Abdominal Pain, -
Constipation, - Hematochezia, + Melena
PULM: + Dyspnea, - Cough, - Hemoptysis
HEME: - Bleeding, - Lymphadenopathy
GU: - Dysuria, - hematuria, - Incontinence
SKIN: - Rash
ENDO: - Heat/Cold Intolerance
MSK: - Myalgia, - Arthralgia, - Back Pain
NEURO: - Numbness, - Weakness, - Vertigo, - Headache
PHYSICAL EXAM:
VSS: 97.9, 90, 156/93, 16, 100%RA
GEN: NAD
Pain: ___
HEENT: EOMI, MMM, - OP Lesions
PUL: CTA B/L
COR: RRR, S1/S2, - MRG
ABD: NT/ND, +BS, - CVAT
EXT: - CCE
NEURO: CAOx3, ___
DISCHARGE EXAM
Vital Signs: 98.3 109/66 80 18 98%RA
Pain ___
GEN: Alert, NAD, AxOx3, speaking full sentences, no accessory
muscle use
HEENT: NC/AT, OP clear, MMM
CV:regular, S1, S2, no m/r/g
PULM: CTA B, no w/r/r
GI: obese, S/ND, BS present, no r/g
PSYCH: talkative, brighter affect than prior days
Pertinent Results:
___ 08:00PM BLOOD ___
___ Plt ___
___ 08:00PM BLOOD ___
___ Im ___
___
___ 08:00PM BLOOD ___ ___
___ 08:00PM BLOOD ___
___
___ 08:00PM BLOOD cTropnT-<0.01 ___
___ 08:00PM BLOOD ___
___ 08:29PM BLOOD ___
___ 08:29PM BLOOD ___ Base
XS--4
___ 08:29PM BLOOD ___
___ 8:00 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
CHEST (PA & LAT) Study Date of ___ 7:34 ___
IMPRESSION:
No acute cardiopulmonary process.
UNILAT LOWER EXT VEINS LEFT Study Date of ___ 9:04 ___
IMPRESSION:
No evidence of deep venous thrombosis in the left lower
extremity veins.
___ ___: There is normal compressibility, flow, and
augmentation of the left common femoral, femoral, and popliteal
veins. Normal color flow and compressibility are demonstrated in
the posterior tibial and peroneal veins. There is normal
respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
No evidence of deep venous thrombosis in the left lower
extremity veins.
___ CTA Chest:
The aorta is unremarkable without dissection or aneurysm. Great
vessels are unremarkable. The pulmonary arteries are well
opacified to the subsegmental level without filling defect to
suggest pulmonary embolism. Pulmonary arteries are normal in
caliber. Left sided central line noted.
There is no evidence of pulmonary parenchymal abnormality. There
is no pleural effusion or pneumothorax. The airways are patent
to the subsegmental level.
Heart is unremarkable. There is no pericardial effusion. There
is no
supraclavicular, axillary, mediastinal, or hilar
lymphadenopathy. Included
portion of the thyroid is unremarkable.
Included portion of the upper abdomen is unremarkable.
No lytic or blastic osseous lesion suspicious for malignancy is
identified. There is no fracture. Spondylosis of the thoracic
spine. Metallic device located in the subcutaneous tissues of
the left breast is visualized.
IMPRESSION: No evidence of pulmonary embolism or aortic
abnormality.
___ TTE: The left atrium is mildly dilated. Left
ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%). The estimated cardiac
index is normal (>=2.5L/min/m2). Tissue Doppler imaging suggests
a normal left ventricular filling pressure (PCWP<12mmHg). Right
ventricular chamber size and free wall motion are normal. The
diameters of aorta at the sinus, ascending and arch levels are
normal. The aortic valve leaflets (3) appear structurally normal
with good leaflet excursion and no aortic stenosis or aortic
regurgitation. The mitral valve appears structurally normal with
trivial mitral regurgitation. The pulmonary artery systolic
pressure could not be determined. There is a trivial/physiologic
pericardial effusion.
IMPRESSION: Normal biventricular cavity sizes with preserved
regional and global biventricular systolic function. No definite
structural cardiac source of embolism identified. Normal PCWP.
___ EGD:
Irregular ___ (biopsy, biopsy)
Erythema and a single erosion in the antrum compatible with
erosive gastritis
Otherwise normal EGD to third part of the duodenum
___ sig: Mild decrease in vascularity in the sigmoid.
Normal vascularity in the rectum. (biopsy, biopsy)
Otherwise normal sigmoidoscopy to sigmoid colon
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 20 mg PO DAILY
2. Metoprolol Tartrate 50 mg PO BID
3. Zolpidem Tartrate 10 mg PO QHS
Discharge Medications:
1. Lisinopril 10 mg PO DAILY
RX *lisinopril 10 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
2. Acetaminophen 1000 mg PO Q8H
RX *acetaminophen 500 mg 2 tablet(s) by mouth every 8 hours Disp
#*180 Tablet Refills:*0
3. Albuterol ___ PUFF IH Q6H:PRN Bronchospasm
RX *albuterol sulfate [ProAir HFA] 90 mcg ___ PUFF INH every 6
hours Disp #*1 Inhaler Refills:*0
4. ARIPiprazole 5 mg PO DAILY
RX *aripiprazole 5 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
5. ARIPiprazole 10 mg PO QHS
RX *aripiprazole 10 mg 1 tablet(s) by mouth at bedtime Disp #*30
Tablet Refills:*0
6. HYDROmorphone (Dilaudid) 2 mg PO TID:PRN pain
RX *hydromorphone 2 mg 1 tablet(s) by mouth twice a day Disp #*3
Tablet Refills:*0
7. Sucralfate 1 gm PO QID
RX *sucralfate 1 gram 1 tablet(s) by mouth 4 times a day Disp
#*28 Tablet Refills:*0
8. Pantoprazole 40 mg PO Q12H
9. Prazosin 5 mg PO QHS
RX *prazosin 5 mg 1 capsule(s) by mouth at bedtime Disp #*30
Capsule Refills:*0
10. Lorazepam 0.5 mg PO QHS:PRN insomnia / anxiety
RX *lorazepam 0.5 mg 0.5 (One half) mg by mouth at bedtime Disp
#*5 Tablet Refills:*0
11. Metoprolol Succinate XL 100 mg PO DAILY
RX *metoprolol succinate 100 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
12. HydrOXYzine ___ mg PO Q6H:PRN itching
RX *hydroxyzine HCl 25 mg ___ tabs by mouth every 6 hours Disp
#*60 Tablet Refills:*0
13. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
14. Ondansetron 4 mg PO Q8H:PRN nausea
RX *ondansetron HCl 4 mg 1 tablet(s) by mouth every 8 hours Disp
#*10 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Chest pain, NOS
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CTA CHEST WITH CONTRAST
INDICATION: ___ year old woman with concern for PE. Needs premedication for
dye allergy // rule out PE
TECHNIQUE: Axial multidetector CT images were obtained through the thorax
after the uneventful administration of 100 cc of Omnipaque intravenous
contrast. Reformatted coronal, sagittal, thin slice axial images, and oblique
maximal intensity projection images were submitted to PACS and reviewed.
DOSE:
Acquisition sequence:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 14.9 mGy (Body) DLP = 3.0
mGy-cm.
4) Stationary Acquisition 2.3 s, 0.2 cm; CTDIvol = 62.9 mGy (Body) DLP =
12.6 mGy-cm.
5) Spiral Acquisition 4.1 s, 30.5 cm; CTDIvol = 17.1 mGy (Body) DLP = 442.7
mGy-cm.
Total DLP (Body) = 458 mGy-cm.
COMPARISON: Chest x-ray ___
FINDINGS:
The aorta is unremarkable without dissection or aneurysm. Great vessels are
unremarkable. The pulmonary arteries are well opacified to the subsegmental
level without filling defect to suggest pulmonary embolism. Pulmonary arteries
are normal in caliber. Left sided central line noted.
There is no evidence of pulmonary parenchymal abnormality. There is no pleural
effusion or pneumothorax. The airways are patent to the subsegmental level.
Heart is unremarkable. There is no pericardial effusion. There is no
supraclavicular, axillary, mediastinal, or hilar lymphadenopathy. Included
portion of the thyroid is unremarkable.
Included portion of the upper abdomen is unremarkable.
No lytic or blastic osseous lesion suspicious for malignancy is identified.
There is no fracture. Spondylosis of the thoracic spine. Metallic device
located in the subcutaneous tissues of the left breast is visualized.
IMPRESSION:
No evidence of pulmonary embolism or aortic abnormality.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Chest pain, Dyspnea
Diagnosed with Other chest pain, Gastrointestinal hemorrhage, unspecified
temperature: 96.2
heartrate: 112.0
resprate: 16.0
o2sat: 100.0
sbp: 146.0
dbp: 107.0
level of pain: 9
level of acuity: 2.0 | ___ with history of ovarian ca s/p ___, prior DVT/PE who
presents with ___ chest pain, exertional tachycardia
associated with palpitations and shortness
of breath. Workup included CXR, CTA chest, EGD/sigmoidoscopy,
and TTE largely without remarkable findings. Significant
psychosocial issues, closely follow by psychiatry and social
work during hospitalization and follow up with ___
Violence Prevention and Recovery set up.
# Chest Pain: Initially concerning for PE but CTA negative, CXR
negative for acute process, ___ negative. EGD done, showing
only
erosive gastritis which could contribute so on PPI, sucralfate.
Sucralfate to stop in one week, BID PPI can be weaned per PCP.
Significant uncontrolled PSTD/depression/anxiety as well as
recent death of daughter thought to be significant contributor
by team and by patient and her husband. Started on aripiprazole,
prazosin, with improving psych symptoms and decreasing dilaudid
requirements for her chest pain. Upon discharge, chest pain
continuing to improve, mostly manageable with Tylenol. Given 3
tabs Dilaudid upon discharge.
# Anxiety/Depression/PTSD: Followed by psychiatry and social
work. Started on Abilify/prazosin with notable improvements in
mood/affect. Given 5 tabs lorazepam for anxiety prior to sleep.
Per patient and husband, they are homeless but upon discharge
husband reported job at ___ and ___. Plan to follow
up in ___.
# Dyspnea on exertion: Initially concern for cardiac etiology,
but CTA, TTE without abnormality that could explain her
symptoms. Noted one episode of dyspnea on exertion with
associated sinus tachycardia. EKG within normal limits and no
evidence of ischemia, tachycardia resolved. Telemetry on
throughout admission without arrhythmia. Could obtain stress as
outpatient if no improvement. Suspect related to deconditioning,
chronicity of this problem is unclear.
* Of note, per patient has loop recorder for history of SVT.
Unable to determine who placed it.
# HTN: Admitted on metoprolol and lisinopril. For psychiatric
symptoms, prazosin was added and BPs decreased notably.
Discharged on lisinopril 10mg (admitted on 20mg) and could be
decreased further as needed. Metoprolol changed to extended
release 100mg XL daily.
# Anemia: Potentially related to GI losses given report of
guaiac + stool in the ED (although negative on the floor). Iron
slightly low but ferritin normal. B12, folate WNL. Stable, no
evidence of bleeding. Can repeat as outpatient.
# Pruritus: Complained of "reaction" to hospital detergent.
Given saran, hydroxyzine prn. No visible rash throughout
hospitalization.
Transitional:
- establish care with new PCP
- follow up in CVPR/psych/social work
- repeat CBC
- BP follow up
- stress test if recurrent DOE |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
codeine
Attending: ___.
Chief Complaint:
Right parietal mass
Major Surgical or Invasive Procedure:
___ Right stereotactic brain biopsy
History of Present Illness:
This is a ___ with newly diagnosed right parietal mass. Pt
reports
having intermittent headaches for a few months. Over the last 2
weeks she developed worsening left hand numbness and a right
sided headache. She denies any F/C/CP/SOB/N/V/dizziness/light
headedness/unsteady gait/LOC. She was seen by her PCP and ___ mass
was found on imaging. She was sent here for further evaluation
Past Medical History:
hypothyroid, tachycardia, recent right oophrectomy and
resection of benign uterine mass
Social History:
___
Family History:
Non-contributory
Physical Exam:
Exam on Admit ___:
O: T: 99.3 BP: 114/62 HR: 76 R 14 98 O2Sats
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: 4 to 2 bilat EOMs intact
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech intact
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, to
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: face symmetric, sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power ___ throughout. No pronator drift
Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally.
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger, rapid alternating
movements, heel to shin
On discharge:
alert and oriented x 3
PERRL
EOMI
face symmetric
MAE ___ strength
Slight L drift
Incision c/d/i
Pertinent Results:
___ 08:25PM BLOOD WBC-8.7 RBC-5.09 Hgb-15.6 Hct-43.9 MCV-86
MCH-30.7 MCHC-35.6* RDW-12.8 Plt ___
___ 08:25PM BLOOD Neuts-85.4* Lymphs-12.3* Monos-1.5*
Eos-0.6 Baso-0.2
___ 08:25PM BLOOD ___ PTT-30.1 ___
___ 08:25PM BLOOD Glucose-141* UreaN-9 Creat-0.7 Na-141
K-3.6 Cl-103 HCO3-21* AnGap-21*
___ 07:00AM BLOOD Calcium-10.1 Phos-4.0 Mg-2.___cm right parietal lobe mass with associated vasogenic
edema.
CHEST CT W/ CONTRAST (___)
1. A right upper paratracheal lymph node is mildly enlarged, 11
mm in diameter.
2. No evidence of intrathoracic metastatic disease.
___ CT Abdomen and pelvis:
4.8 cm complex right adnexal mass. Per history, the patient has
had a recent right oophorectomy but this appearance is not
consistent with a postoperative collection. Further evaluation
with MRI is recommended.
Radiology Report MR HEAD W & W/O CONTRAST Study Date of
___ 4:04 ___
IMPRESSION:
1. Two adjacent 2.9 and 1.8 cm enhancing masses in the right
frontoparietal lobe with necrosis, blood products, areas of
slowed diffusion consistent with dense cellularity, and marked
surrounding vasogenic edema most consistent with a high-grade
glioma. The 2.9 cm mass is predominantly within the right
parietal lobe with some extension into the frontal lobe and the
1.8 cm mass also appears to bridge the frontal and parietal
lobes.
2. Ill-defined foci of enhancement measure up to 7 mm within the
deep white matter and cortex of the high right parasagittal
parietal lobe. This appears to be parenchymal enhancement
associated with the two dominant enhancing masses.
Cardiovascular Report ECG Study Date of ___ 11:12:42 AM
Sinus rhythm. Left axis deviation. Compared to the previous
tracing
of ___ no diagnostic change.
Read by: ___.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
77 182 92 386/415 56 -32 61
Radiology Report MR HEAD W/ CONTRAST Study Date of ___
7:30 AM
IMPRESSION:
Sterotactic frame in place. Two right frontoparietal
heterogeneous enhancing masses with surrounding vasogenic edema,
representing metastatic disease or primary tumor, are overall
unchanged from the prior exam.
Radiology Report CT HEAD W/O CONTRAST Study Date of ___
11:38 AM
IMPRESSION: Expected post-surgical changes following biopsy of
right parietal lobe mass.
Radiology Report MR PELVIS W&W/O CONTRAST Study Date of
___ 1:15 AM
IMPRESSION:
1. Rounded mass arising from the right cervix, most likely an
exophytic
fibroid with degeneration. Please correlate with prior imaging
to determine the stability of this lesion and if none are
available, followup with pelvic ultrasound is recommended in 6
months.
2. Diverticulosis of the sigmoid.
RECOMMENDATIONS: Correlation with prior imaging is recommended
to determine the stability of this lesion appearing to arise
from the right cervix and if none are available, followup with
pelvic ultrasound is recommended in 6 months.
Medications on Admission:
amitripytline, levothyroxine, nadolol, sertraline, simvastatin
Discharge Medications:
1. Amitriptyline 10 mg PO QHS
2. Famotidine 20 mg PO BID
RX *famotidine 20 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*2
3. LeVETiracetam 500 mg PO BID
RX *levetiracetam [Keppra] 500 mg 1 tablet(s) by mouth twice a
day Disp #*60 Tablet Refills:*2
4. Levothyroxine Sodium 25 mcg PO DAILY
5. Multivitamins 1 TAB PO DAILY
6. Nadolol 40 mg PO DAILY
7. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H:PRN pain
RX *oxycodone-acetaminophen 5 mg-325 mg ___ tablet(s) by mouth
Q4-6 H PRN pain Disp #*60 Tablet Refills:*0
8. Sertraline 50 mg PO DAILY
9. Simvastatin 20 mg PO QPM
10. Dexamethasone 3 mg PO Q6H Duration: 48 Hours
3mgQ6x 2 days, 3mg Q8 x 2 days, 3mg Q12 x 2 days, 2mg Q12
ongoing
RX *dexamethasone 1 mg 1 tablet(s) by mouth taper per
instructions Disp #*90 Tablet Refills:*3
11. Lorazepam 0.5 mg PO Q12H:PRN anxiety
RX *lorazepam 0.5 mg 1 tab by mouth Q12H PRN anxiety Disp #*10
Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Right parietal mass
Right adnexal mass
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
INDICATION: ___ F new rt brain mass on CT // Pls eval for primary lesion. The
patient reportedly had a recent right oophorectomy and resection of a benign
uterine mass.
COMPARISON: None.
FINDINGS:
LOWER CHEST:
Please refer to separate report of CT chest performed on the same day for
description of the thoracic findings.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesions. There is no evidence of intrahepatic
or extrahepatic biliary dilatation. The gallbladder is surgically absent.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There is no evidence of stones, focal renal lesions or hydronephrosis. There
are no urothelial lesions in the kidneys or ureters. There is no perinephric
abnormality.
GASTROINTESTINAL: Small bowel loops demonstrate normal caliber, wall
thickness and enhancement throughout. Diverticulosis of the sigmoid colon is
noted, without evidence of wall thickening and fat stranding.. Appendix
contains air, has normal caliber without evidence of fat stranding.
RETROPERITONEUM: There is no evidence of retroperitoneal and mesenteric
lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. There is minimal calcium
burden in the abdominal aorta and great abdominal arteries.
PELVIS:
The urinary bladder and distal ureters are unremarkable. There is no evidence
of pelvic or inguinal lymphadenopathy. There is no free fluid in the pelvis.
REPRODUCTIVE ORGANS: 4.8 x 3.7 cm mass in the right adnexa has solid and
cystic components (2:98). A normal uterus is not visualized. The left adnexa
is unremarkable.
BONES AND SOFT TISSUES:
There is no evidence of worrisome lesions. Abdominal and pelvic wall is within
normal limits.
IMPRESSION:
4.8 cm complex right adnexal mass. Per history, the patient has had a recent
right oophorectomy but this appearance is not consistent with a postoperative
collection. Further evaluation with MRI is recommended.
TECHNIQUE: MDCT axial images were acquired through abdomen and pelvis
following intravenous contrast administration with split bolus technique.
Coronal and sagittal reformations were performed and reviewed on PACS.
Oral contrast was administered.
MDCT images were obtained from the lung bases to the lesser trochanters after
the administration of intravenous contrast. Coronal and sagittal reformations
were prepared.
DOSE: DLP: ___ MGy-cm (chest abdomen and pelvis.
IV Contrast: 130 mL Omnipaque
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST
INDICATION: ___ F newly diagnosed parietal brain mass // eval mass
TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After
administration of 7cc of Gadavist intravenous contrast, axial imaging was
performed with gradient echo, FLAIR, diffusion, and T1 technique. Sagittal
MPRAGE imaging was performed and re-formatted in axial and coronal
orientations
COMPARISON: Noncontrast CT head ___
FINDINGS:
There is a 2.6 x 2.9 x 2.6 cm (AP x TV x SI) enhancing intra-axial mass in the
right frontoparietal lobe (series 13, image 14). Just laterally within the
right frontoparietal lobe, there is a 1.1 x 1.7 x 1.8 cm enhancing intra-axial
mass (series 13, image 14). Within the posterior parietal lobe, there are a
few foci of ill-defined enhancement that appear to be within the deep white
matter and cortex and measure up to 7 mm (series 14, image 92). Enhancing
parts of the two largest masses demonstrate slowed diffusion consistent with
dense cellularity. T1 hypointense, T2 hyperintense portions of the two largest
masses demonstrate CSF signal on diffusion weighted images, consistent with
necrosis or cystic change. There are blood products in the largest mass.
There is extensive surrounding vasogenic edema throughout the right parietal,
frontal, and temporal lobes. There is mass effect on the occipital horn of the
right lateral ventricle but no midline shift or effacement of the cisterns.
Major intravascular flow voids are preserved. There is normal patency of the
major intracranial arteries and dural venous sinuses following contrast
administration.
Marrow signal is within normal limits. There is mild mucosal thickening of the
ethmoid and left maxillary sinuses. There is a mucous retention cyst in the
left posterior nasal cavity or sphenoid sinus. The mastoid air cells appear
clear. There has been bilateral lens surgery.
IMPRESSION:
1. Two adjacent 2.9 and 1.8 cm enhancing masses in the right frontoparietal
lobe with necrosis, blood products, areas of slowed diffusion consistent with
dense cellularity, and marked surrounding vasogenic edema most consistent with
a high-grade glioma. The 2.9 cm mass is predominantly within the right
parietal lobe with some extension into the frontal lobe and the 1.8 cm mass
also appears to bridge the frontal and parietal lobes.
2. Ill-defined foci of enhancement measure up to 7 mm within the deep white
matter and cortex of the high right parasagittal parietal lobe. This appears
to be parenchymal enhancement associated with the two dominant enhancing
masses.
Radiology Report
EXAMINATION: Chest CT
INDICATION: Ambulation of the patient with brain lesion
TECHNIQUE: MDCT of the chest was obtained from thoracic inlet to upper
abdomen. Axial images were reviewed in conjunction with coronal and sagittal
reformats
COMPARISON: None.
FINDINGS:
Aorta and pulmonary arteries. Assessment demonstrate normal pattern of
enhancement and atherosclerotic disease of the aorta, mild. A right upper
paratracheal lymph node is mildly enlarged, 11 mm in diameter. No hilar or
sub- carinal or axillary lymphadenopathy is present. Heart size is normal.
There is no pericardial pleural effusion. Image portion of the upper abdomen
reveals no appreciable abnormality
Airways are patent to the subsegmental level bilaterally. Bilateral apical
opacities most likely represent areas of scarring. Centrilobular nodules are
noted bilaterally, diffuse and might represent respiratory bronchiolitis or
airway infection/ inflammation unrelated to smoking. No discrete masses noted.
Interstitial fibrosis, focal a adjacent to the right spinal osteophyte is
present, chronic. No interstitial lung disease is demonstrated.
There are no lytic or sclerotic lesions worrisome for infection or neoplasm.
IMPRESSION:
No evidence of intrathoracic metastatic disease.
For assessment of the upper abdomen please review CT abdomen and the
corresponding report.
The only abnormality detected is mildly enlarged right paratracheal lymph node
that should be reassessed in 3 months for documentation of stability.
Radiology Report
EXAMINATION: MR HEAD W/ CONTRAST
INDICATION: ___ year old woman with right parietal brain mass.
TECHNIQUE: After administration of 70-cc of Gadavist intravenous contrast,
axial imaging was performed with MPRAGE and T1 technique. MPRAGE images were
re-formatted in sagittal and coronal orientations.
COMPARISON: MR head dated ___.
FINDINGS:
The sterotactic frame is in place. Two right frontoparietal intra-axial
enhancing heterogeneous masses are again demonstrated and overall unchanged in
appearance, the more medial, larger mass measures 2.6 x 2.8 cm and the smaller
adjacent one measures 1.9 x 1.7 cm. The larger mass has some blood products as
demonstrated before. Surrounding vasogenic edema is also grossly unchanged
involving the right parietal, frontal, and temporal lobes. Mass effect on the
occipital horn of the right lateral ventricle persists and is grossly
unchanged. There is no midline shift. The cisterns are patent. Small vessel
ischemic diseases are seen in the white matter.
IMPRESSION:
Sterotactic frame in place. Two right frontoparietal heterogeneous enhancing
masses with surrounding vasogenic edema, representing metastatic disease or
primary tumor, are overall unchanged from the prior exam.
Radiology Report
EXAMINATION: MR PELVIS WANDW/O CONTRAST
INDICATION: ___ year old woman with history of uterine mass resection now with
right-sided adnexal mass. // Further assessment of adnexal mass.
TECHNIQUE: Multiplanar T1 and T2 weighted MR images of the pelvis were
obtained on a 1.5 Tesla magnet including dynamic 3D imaging prior to, during,
and after the administration of 7 mL Gadavist gadolinium based contrast.
COMPARISON: CT abdomen and pelvis from ___.
FINDINGS:
The patient appears to be status post supracervical hysterectomy. Neither
ovary is clearly identified. Nabothian cysts are seen in the cervix.
4.8 x 3.5 x 3.3 cm well-defined rounded mass arising from the right aspect of
cervix is seen (04:23). The rim of the mass is isointense to hypointense on
T2WI and is enhancing. There are internal T2 hyperintense nonenhancing
components, consistent with cystic spaces (5:5, 101:40) as well as enhancing
internal septations. There are no blood products. There is no nodular
enhancement.
There is tiny amount of free fluid in the pelvis. The partially distended
bladder is grossly unremarkable. There is diverticulosis in the sigmoid colon,
without signs of diverticulitis. There is no significant pelvic or inguinal
lymphadenopathy. The osseous structures are unremarkable.
IMPRESSION:
1. Rounded mass arising from the right cervix, most likely an exophytic
fibroid with degeneration. Please correlate with prior imaging to determine
the stability of this lesion and if none are available, followup with pelvic
ultrasound is recommended in 6 months.
2. Diverticulosis of the sigmoid.
RECOMMENDATIONS: Correlation with prior imaging is recommended to determine
the stability of this lesion appearing to arise from the right cervix and if
none are available, followup with pelvic ultrasound is recommended in 6
months.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ year old female status-post brain biopsy of a right parietal
lobe mass.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: DLP: 922 mGy-cm
CTDI: 53 mGy
COMPARISON: MR head from ___.
FINDINGS:
Study is limited by motion artifact. Expected post-biopsy changes with
pneumocephalus and subcutaneous emphysema. Two right parietal masses are again
demonstrated, better characterized on MR. ___ extensive vasogenic edema
is unchanged. Mass effect from the largest right parietal mass is unchanged.
The overall configuration and size of the ventricles is unchanged from the
prior MR. ___ cisterns are patent. The partially visualized paranasal sinuses,
mastoid air cells, and middle ear cavities are grossly clear. The orbits are
unremarkable.
IMPRESSION:
Expected post-surgical changes following biopsy of right parietal lobe mass.
NOTIFICATION: The findings were conveyed by Dr. ___ with Dr. ___
___ from the referring neurosurgery team via text page on ___ at
12:04 ___, 1 minutes after discovery of the findings.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Headache
Diagnosed with BRAIN CONDITION NOS, SKIN SENSATION DISTURB
temperature: 98.1
heartrate: 62.0
resprate: 18.0
o2sat: 99.0
sbp: 146.0
dbp: 67.0
level of pain: 4
level of acuity: 2.0 | ___ y/o female admitted to Neurosurgery Service due to imaging
findings of a right parietal mass. MRI Head ordered for further
diagnostic imaging. A Chest/Abdomen/Pelvic CT was performed on
___ to evaluate for malignancy involvement showing no
evidence of inrathoracic metastatic disease, only a right upper
paratracheal lymph node is mildly enlarged measuring 11 mm in
diameter. The Abdomen/Pelvic CT showed 4.8 cm complex right
adnexal mass and of note, the pt has a history of a recent right
oophorectomy but this appearance is not consistent with a
postoperative collection. Further evaluation with MRI is
recommended.
Overnight into ___, Ms. ___ was in the bathroom
attempting to ambulate from the toilet when she experienced left
lower extremity weakness and impaired sensation consistent with
her presenting symptomology. At this time Ms. ___ was
able to gradually lower herself to the floor and onto her knees.
On ___, gynecology was consulted for Mrs. ___ right
adnexal mass. She was consented and pre-op'ed for a right
stereotactic biopsy of her parietal mass (scheduled for ___.
On ___, The patient went to the OR for a steriotactic biopsy by
Dr ___. A post operative NCHCT was performed and was
consistent with expected post operative changes. The patient
was initiated on decadron 4 q 6. Pepcid and a regular sliding
scale were initiated while the patient was on steroids. The
patient experienced some mild nausea post operatively. The
patients serum postassium was low and was repleated.
On ___, The patient would like to ___ rehab placement.MRI
of the pelvis was perfomed and Rounded mass arising from the
right cervix, most likely an exophytic
fibroid with degeneration. Please correlate with prior imaging
to determine
the stability of this lesion and if none are available, follow
up with pelvic
ultrasound is recommended in 6 months. Diverticulosis of the
sigmoid.
On ___, The patient is requesting ___ rehab in ___.
The pelvic mass found on MRI was discussed and the patient will
follow up outpatient with their GYN to follow this mass. The
patients decadron was weaned to 2mg bid.
On ___ Patient was neurologically intact. She was re-evaluated
by ___ who determined she was safe for discharge home with home
___, OT and ___ services. ___ as discharged home in stable
condition with instructions for follow up |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Codeine / Penicillins
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
___ Laparoscopic Cholecystectomy
History of Present Illness:
___ F w/ 18 hrs of abdominal pain prior to presentation. The
patient states that
she had abrupt onset abdominal pain starting the evening prior
to presentation.
She has not had any nausea/vomiting. She has a history of GERD,
but states that this feels significantly different than her
previous GERD symptoms. She had one episode of vomiting, no
fevers/chills. She has never had any previous biliary disease.
Past Medical History:
HL, Hepatitis (unknown type), Narrow angle glaucoma
Social History:
___
Family History:
Noncontributory. No malignancy
Physical Exam:
Vitals: 99.7 80 124/74 16 100RA
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, Tender RUQ/Midepigastric, no guarding or rebound
Ext: No ___ edema, ___ warm and well perfused
Pertinent Results:
___ 09:06AM LACTATE-2.5*
___ 08:56AM GLUCOSE-123* UREA N-16 CREAT-0.8 SODIUM-140
POTASSIUM-3.5 CHLORIDE-102 TOTAL CO2-25 ANION GAP-17
___ 08:56AM estGFR-Using this
___ 08:56AM ALT(SGPT)-138* AST(SGOT)-175* ALK PHOS-97 TOT
BILI-0.9
___ 08:56AM LIPASE-2965*
___ 08:56AM ALBUMIN-4.1
___ 08:56AM ALBUMIN-4.1
___ 08:56AM WBC-18.5*# RBC-4.76 HGB-14.8 HCT-44.3 MCV-93
MCH-31.0 MCHC-33.3 RDW-13.6
___ 08:56AM NEUTS-91.1* LYMPHS-4.3* MONOS-4.2 EOS-0.4
BASOS-0.1
___ 08:56AM PLT COUNT-257
___ 08:56AM ___ PTT-26.2 ___
___ 08:30AM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 08:30AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.5
LEUK-NEG
___ 08:30AM URINE RBC-1 WBC-<1 BACTERIA-NONE YEAST-NONE
EPI-1
___ 08:30AM URINE MUCOUS-RARE
Medications on Admission:
PPI, Halcion 0.25 mg qd, HCTZ 25 mg qd
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
RX *acetaminophen 650 mg 1 tablet(s) by mouth four times a day
Disp #*30 Tablet Refills:*0
2. Famotidine 20 mg PO DAILY
RX *famotidine [Heartburn Relief] 10 mg 1 tablet(s) by mouth
daily Disp #*30 Tablet Refills:*0
3. OxycoDONE (Immediate Release) 2.5-5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth four times a day Disp
#*30 Tablet Refills:*0
4. Hydrochlorothiazide 25 mg PO DAILY PRN edema
RX *hydrochlorothiazide 25 mg 1 tablet(s) by mouth once a day
Disp #*14 Tablet Refills:*0
5. TRIAzolam 0.25 mg PO HS PRN insomnia
6. Multivitamins 1 TAB PO DAILY
7. Calcium Carbonate 500 mg PO DAILY
RX *calcium carbonate [Antacid] 200 mg calcium (500 mg) 1
tablet(s) by mouth twice a day Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Gallstone pancreatitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Chest pain and epigastric pain.
TECHNIQUE: Frontal lateral views of the chest.
COMPARISON: None.
FINDINGS:
There is mild left base atelectasis. No focal consolidation is seen. There
is no large pleural effusion. No pneumothorax is seen. Minimal biapical
pleural parenchymal thickening is seen. The aorta is somewhat tortuous. The
cardiac silhouette is not enlarged. No evidence of free air is seen beneath
the diaphragms.
IMPRESSION:
Minimal left base atelectasis. No focal consolidation. No evidence of free
air beneath the diaphragms.
Radiology Report
HISTORY: Right upper quadrant epigastric pain. Tender to palpation and
epigastric region and vomiting. Question cholecystitis.
TECHNIQUE: Grayscale and Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: None available.
FINDINGS:
The liver shows no evidence of focal lesions or textural abnormality. There
is no evidence of intra or extrahepatic biliary dilatation and the common bile
duct measures 4 mm. The gallbladder demonstrates sludge and small stones
measuring up to 3 mm. There is no gallbladder wall thickening or
pericholecystic fluid. The pancreas is unremarkable without evidence of focal
lesions or pancreatic duct dilatation. The spleen measures 7.8 cm and has a
homogeneous echotexture. The right and left kidneys are normal without
masses, hydronephrosis or stones. The right kidney measures 10.4 cm and the
left kidney measures 8.9 cm. The aorta is of normal caliber throughout. The
visualized portion of the inferior vena cava appears normal.
IMPRESSION:
Cholelithiasis and gallbladder sludge with no evidence of acute cholecystitis.
Radiology Report
HISTORY: Gallstone pancreatitis. Evaluate for CBD stone.
TECHNIQUE: Multiplanar T1 and T2 weighted images were acquired on a 1.5T
magnet including dynamic 3D imaging obtained prior to, during and after the
uneventful intravenous administration of 5 mL of Gadavist. The patient also
received 2.5 mL of Gadavist diluted with water p.o.
FINDINGS:
Pericholecystic fluid is noted surrounding the gallbladder and there are
multiple gallstones within the gallbladder. The gallbladder wall is not
thickened and enhances normally post-contrast. There is cystic change and
thickening of the fundus of the gallbladder consistent with adenomyomatosis
(sequence 9 image 28). No intra or extrahepatic duct dilatation. No filling
defects within the biliary tree.
The pancreas is normal in signal intensity and enhances normally
post-contrast. No peripancreatic fat stranding.
Within segment VII of the liver, there is a peripheral area of wedge-shaped
enhancement on the arterial phase which appears to be surrounding a small
cyst (sequence 16 image 6). The enhancement does not persist on the portal
venous or delayed phase. No diffusion abnormality is demonstrated within the
liver. There are mutliple subcentimeter T2 hyperintense lesions in the liver
which likely represent small cysts. The liver is otherwise unremarkable. The
portal and hepatic veins are patent. The hepatic artery is patent with
conventional hepatic arterial anatomy.
There are multiple peripelvic and simple cysts within both kidneys, more
marked on the left than the right. The kidneys are otherwise unremarkable.
There are single renal arteries bilaterally. The adrenals and spleen are
within normal limits.
There is a 3.9 cm diverticulum arising from the third part of the duodenum and
contains oral contrast within it (seq 16 im 60). The visualized small and
large bowel is otherwise unremarkable. A 0.6 cm lymph node is noted at the
porta hepatis (sequence 6 image 64). There is also a 0.5 cm lymph node
adjacent to the falciform ligament (sequence 6 image 57). Bibasal
atelectasis is noticed within the lung bases. There is scoliosis of the upper
lumbar spine convex to the right. Bone marrow signal is normal. No
destructive osseous lesions.
IMPRESSION:
1. No evidence of CBD calculi or biliary obstruction.
2. Cholelithiasis. Pericholecystic fluid surrounding the gallbladder. No
features suggestive of cholecystitis.
3. Adenomyomatosis at the gallbladder fundus.
4. Normal pancreas. No features suggestive of pancreatitis.
5. Peripheral enhancement within segment VII of the liver which likely
represents a perfusion anomaly, although hepatitis is not outruled.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: EPIGASTRIC PAIN
Diagnosed with ACUTE PANCREATITIS, CHOLELITHIASIS NOS
temperature: 98.6
heartrate: 85.0
resprate: 16.0
o2sat: 98.0
sbp: 120.0
dbp: 66.0
level of pain: 5
level of acuity: 2.0 | The patient presented on ___ with the complaint of abdominal
pain. The MRCP demonstrated cholelithiasis and gallbladder
sludge with no evidence of acute cholecystitis. The patient was
taken to the operating theater for definitive management of her
gallstone pancreatitis. The procedure was explained to the
patient and a consent was obtained. On ___ Ms. ___
underwent uncomplicated laparoscopic cholecystectomy by Dr. ___
___. ___ was discharged after tolerating PO fluids/ solids
without concerns and return of bowel function with both flatus
and stool production. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Left-sided facial rash and altered mental status
Major Surgical or Invasive Procedure:
Lumbar puncture ___
Nasogastric tube placement
History of Present Illness:
CC: L eye discharge, rash
HPI: ___ with hx of Graves' disease, htn, mild cognitive
impairment, recent evaluation in ___ ED on ___ for
headache
and concern for zoster presenting with increased L eye
discharge.
History is obtained from review of OMR, discussion with pt's son
___ overnight and - to a limited extent - from pt, who is
somewhat confused on arrival to the floor at 1 am. Son, ___,
describes onset of significant headache ___, which initially
responded to ibuprofen and Tylenol. Headache then became more
pronounced on ___. Pt reported to ___ that he had developed
terrible pain over the L sided of his face on ___ pm. Pt was
initially seen in ___ for headache x6 days on ___. At that
time, he apparently described ___ headache, sharp, without
significant relief from Tylenol or advil. He denied F/C, N/V,
visual changes, rash at that time. He was noted to have area of
redness over L forehead, conjunctivitis of L eye, pain with L
EOMI, and photophobia, without ear imvolvement. Fluoroscein exam
at that time "no dendritic lesion." He was prescribed
valacyclovir 1 gm PO q8h x7 days, and gabapentin 100 mg PO TID
x3
days, and discharged back to ___.
On ___, brother ___ noted increased eye involvement with
thick yellow discharge from L eye, and bilateral eyelid edema;
after discussion with RN at ___ by phone, decision was
made to go to the ED for further care. Prior to presentation, pt
was not reporting painful eye at rest. According to son ___, at
no point did he describe visual changes, F/C. Rash was first
noticed on arrival to the ED on ___.
According to ___, pt has had progressive cognitive decline over
the past 5 months. Increasingly, he has difficulty with time,
calling sons in the middle of the night not realizing what time
it is. He has always recognized all members of the family; on
the
day of presentation, son ___ noted markedly increased confusion,
pt trying to eat a towel, said that someone was downstairs
trying
to buy crackers and cheese. ___ reports that he has never seen
pt quite like that, although has noted significantly increased
confusion over the past 5 months.
In the ___ ED:
VS 98.6, 78, 170/82, 96% RA
Exam notable for copious purulent discharge from L eye, severe
conjunctivitis, minimal discharge in R, early vesicular rash on
V1/V2, concern for dendritic lesion on L eye, difficult to
obtain
exam
Labs notable for
- CBC: 7.7/14.0/42.6/235
- Lytes: ___
- UA: negative for UTI
Consults:
Ophthalmology - "Possible Herpes Zoster anterior uveitis and
epithelial keratitis left eye. Slit lamp exam was deferred due
to
patient comfort/infirmity. On bedside exam, his injection and
elevated IOP OS are consistent with HSV iritis. He had SPK that
was dendritiform in the left eye, though without classic
dendrite. However, he does have crusting of his RIGHT lower lid
as well. This could be reactive discharge from both eyes, but
primary team may consider other etiologies for his rash such as
impetigo. From an ophthalmic perspective, we will treat him for
HSV iritis and keratitis OS."
Received:
IVF
Labetalol 5 mg IV
Acyclovir 600 mg IV
Tylenol ___ mg PO
Metoprolol tartrate 25 mg
Brimonidine tartrate 0.15% ophth 1 drop
Cyclopentolate 1% 1 drop
Erythromycin 0.5% ophth ointment 0.5 in
On arrival to the floor, pt endorses pain over L eye. History
obtained as above.
ROS: Limited by AMS
Past Medical History:
Sciatica
BPH s/p shaving and laser light therapy
Memory loss
Constipation
EtOH use disorder
Tinnitus - L ear, since age ___
Bilateral hearing loss
Graves' disease - labs from ___ with hyperthyroidism, scan
___ with uniform uptake of 62%, consistent with Graves'
disease, started on methimazole
C. diff infection
Social History:
___
Family History:
Mother died in her ___ of a stroke. Father died
in his ___ of a myocardial infarction. A brother died from a
motor vehicle accident midlife.
Physical Exam:
ADMISSION:
===========
VS: 97.4 AdultAxillary 203/105->170/80Manual 60 20 96 Ra
GEN: elderly male lying in bed with facial rash, alert and
interactive, comfortable, no acute distress
HEENT: Pupils are dilated, symmetric, not responsive to light
and
accommodation after dilation in ED. Copious yellow discharge
from
L eye, scant yellow crusting over R eye. + L>R conjunctival
injection. Erythema and edema with crusted, scaling rash
surrounding L eye, with occasional crusted vesicle, in V1/V2
distribution. Oropharynx without
lesion or exudate, moist mucus membranes, ears without lesions
or
apparent trauma
LYMPH: no anterior/posterior cervical, supraclavicular
adenopathy
CARDIOVASCULAR: Regular rate and rhythm without murmurs, rubs,
or
gallops
LUNGS: coarse breath sounds with occasional crackles at R base,
otherwise clear to auscultation bilaterally without rhonchi,
wheezes, or crackles
GI: soft, nontender, without rebounding or guarding,
nondistended
with normal active bowel
sounds, no hepatomegaly appreciated
EXTREMITIES: 1+ bilateral pitting edema, with R>L ___ erythema,
warmth, scaling, WWP
GU: no foley
SKIN: Facial rash and scaling over RLE as above
NEURO: Alert and interactive to person, "emergency room...."
unable to name type or name of building, year is ___ Hard of
hearing, able to state that he lives at ___, then
perseverates on the specific address ___. Bilateral
extraocular muscles intact with pain with L eye movement.
Strength is ___ in UE and ___ bilaterally.
PSYCH: normal mood and affect
DISCHARGE:
==========
24 HR Data (last updated ___ @ 827)
Temp: 97.9 (Tm 97.9), BP: 139/83, HR: 114 (88-114), RR: 18
(___), O2 sat: 94%, O2 delivery: RA
GEN: Elderly male sleeping/lying almost flat in bed. Mild
agitated distress.
HEENT: No discharge from left eye. Left conjunctival injection
decreased. Crusted rash surrounding left eye and face and scalp;
underlying erythema is unchanged, but edema is decreasing. No
vesicles noted. Scattered excoriations likely from sloughed
skin/crust are scabbing. Oropharynx without lesion; but with
unchanged significant thick mucous; moist mucus membranes. Left
eye ~6 mm and minimally reactive, right eye not dilated and more
reactive to light (ophthalmology states left eye changes are
related to eye drops). Slight perioral blunting on left that
improves with smile.
CARDIOVASCULAR: Heart regular rate and rhythm. No murmur. Radial
and DP pulses 2+.
LUNGS: Bibasilar crackles, unchanged.
GI: Abdomen is soft, nontender, nondistended, normal active
bowel sounds
EXTREMITIES: Trace bilateral pitting edema, unchanged.
SKIN: Facial rash and scaling as above
NEURO: Sleepy, but arousable for brief conversation. Oriented to
person (doctor) and place (hospital). Strength not assessed due
to increased agitation today. Patient raises both arms equally
against gravity and moving both legs spontaneously.
PSYCH: Pleasant.
Pertinent Results:
ADMISSION:
==========
___ 02:50PM BLOOD WBC-7.7 RBC-4.43* Hgb-14.0 Hct-42.6
MCV-96 MCH-31.6 MCHC-32.9 RDW-14.5 RDWSD-50.6* Plt ___
___ 02:50PM BLOOD Neuts-69.9 Lymphs-12.6* Monos-15.2*
Eos-1.3 Baso-0.6 Im ___ AbsNeut-5.38 AbsLymp-0.97*
AbsMono-1.17* AbsEos-0.10 AbsBaso-0.05
___ 02:50PM BLOOD Glucose-103* UreaN-23* Creat-1.0 Na-132*
K-4.6 Cl-95* HCO3-24 AnGap-13
___ 09:50PM BLOOD CK-MB-7 cTropnT-<0.01
___ 06:50AM BLOOD Calcium-9.0 Phos-3.1 Mg-1.7
___ 06:50AM BLOOD TSH-6.8*
___ 06:50AM BLOOD Free T4-0.9*
DISCHARGE:
==========
XXXXX
UA (straight cath): tr blood, neg nit, 100 prot, neg ___, 3 RBCs,
< 1 WBC
UNa 154, Uosm 767 (before IVFs, it appears)
CSF (___): TNC 4, 3 RBCs, 4% PMNs, 3% other, Tprot 152, Glu 57
HSV PCR CSF (___): pending
Enterovirus CSF (___): pending
CSF (___): 1+ PMNs, no organisms; Cx pending
UCx (___): negative
BCx (___): pending
IMAGING:
========
LP (___):
Report pending
NCHCT (___):
1. No acute intracranial findings. No mass or mass effect.
2. Sequela from chronic small vessel disease bilaterally.
TTE:
Normal left ventricular wall thickness and biventricular cavity
sizes and regional/
global systolic function. Mild pulmonary artery systolic
hypertension. No prior TTE available for
comparison.
MRI Head:
1. No evidence of acute infarction, hemorrhage or intracranial
mass. There is
mild enhancement of the left trigeminal nerve within Meckel's
cave,
potentially reflective of herpes zoster. There is also
suggestion of mild
nonspecific dural thickening along the internal auditory canals,
potentially
representative of lumbar puncture sequela, although infectious
process not
entirely excluded. No other abnormal intracranial enhancement.
2. Extensive white matter changes in the cerebral hemispheres
bilaterally and
in the pons, likely sequela of chronic small vessel ischemic
changes. Small
punctate infarct in the left anterior corona radiata.
3. Additional findings described above.
EEG:
IMPRESSION: This is an abnormal continuous video-EEG monitoring
study due to:
1. Intermittent runs of semi-rhythmic delta activity over the
right central-
temporal region, indicative of focal cerebral dysfunction,
non-specific as to
etiology.
2. Generalized slowing with rare broad based right>left
triphasic waves,
indicative of a moderate encephalopathy, which is nonspecific
with regard to
etiology.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Sertraline 100 mg PO DAILY
2. ValACYclovir 1000 mg PO Q8H
3. Gabapentin 100 mg PO TID
4. Metoprolol Tartrate 50 mg PO DAILY
5. MethIMAzole 7.5 mg PO DAILY
6. Finasteride 5 mg PO DAILY
7. Align (Bifidobacterium infantis) 4 mg oral DAILY
8. Vitamin D ___ UNIT PO DAILY
9. Cyanocobalamin 1000 mcg PO DAILY
10. niacinamide 500 mg oral BID
11. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP BID
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever
RX *acetaminophen 500 mg 2 tablet(s) by mouth Q8H PRN Disp #*10
Tablet Refills:*0
2. Artificial Tears ___ DROP BOTH EYES Q4H
RX *dextran 70-hypromellose (PF) [Artificial Tears (PF)] 0.1
%-0.3 % 1 application ophth twice a day Disp #*1 Tube Refills:*0
3. Erythromycin 0.5% Ophth Oint 0.5 in LEFT EYE BID
RX *erythromycin 5 mg/gram (0.5 %) 1 application left eye twice
a day Refills:*0
4. LevETIRAcetam 500 mg PO Q12H
RX *levetiracetam 500 mg 1 tablet(s) by mouth twice a day Disp
#*10 Tablet Refills:*0
5. LORazepam 1 mg PO Q8H:PRN anxiety or agitation
RX *lorazepam 1 mg 1 tablet(s) by mouth Q8H PRN Disp #*10 Tablet
Refills:*0
6. Morphine Sulfate (Concentrated Oral Solution) 20 mg/mL ___
mg PO Q2H:PRN Moderate to severe pain
RX *morphine concentrate 20 mg/mL ___ ml by mouth Q3H PRN Disp
#*3 Syringe Refills:*0
7. Senna 8.6 mg PO BID:PRN Constipation
RX *sennosides [senna] 8.6 mg 1 tablet(s) by mouth BID PRN Disp
#*10 Tablet Refills:*0
8. Timolol Maleate 0.5% 1 DROP LEFT EYE BID
RX *timolol maleate 0.5 % 1 drop ophth twice a day Refills:*0
9. ValACYclovir 1000 mg PO Q12H
10. MethIMAzole 7.5 mg PO DAILY
11. Metoprolol Tartrate 50 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Dysphagia
Malnutrition
Varicella zoster ophthalmicus and encephalitis
Possible Seizure activity: trigger of CNS infection versus PRES.
Acute metabolic encephalopathy: Multifactorial from VZV
encephalitis,
PRES, hospital/illness-related delirium, infection associated
metabolic encephalopathy, hyponatremia, progressive or
decompensated cognitive decline with probable dementia,
malnutrition and deconditioning, delirium
Ecoli urinary tract infection
Hypertensive urgency
SVT
Acute renal failure: pre-renal azotemia
Possible diastolic congestive heart failure
Headache
Hyponatremia, likely SIADH
Hypovolemic hypernatremia
Graves disease
Depression
Benign prostatic hyperplasia
Discharge Condition:
Mental Status: Confused - always.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD.
INDICATION: ___ year old man with likely localized Zoster and AMS. Plan for
LP.// Please eval for mass effect.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Spiral Acquisition 11.2 s, 23.0 cm; CTDIvol = 51.9 mGy (Head) DLP =
1,198.3 mGy-cm.
Total DLP (Head) = 1,198 mGy-cm.
COMPARISON: CT ___.
FINDINGS:
There is no evidence of infarction, hemorrhage, edema, or mass. There is
prominence of the ventricles and sulci suggestive of involutional changes.
Diffuse periventricular and subcortical white matter hypodensities are
demonstrated bilaterally, consistent with sequela from chronic small vessel
disease. Dense vascular atherosclerotic calcifications are seen in the
carotid siphons and distal vertebral arteries.
There is no evidence of fracture. There is fluid within the bilateral ethmoid
air cells, otherwise the visualized portion of the paranasal sinuses, mastoid
air cells, and middle ear cavities are clear. The visualized portion of the
orbits are unremarkable.
IMPRESSION:
1. No acute intracranial findings. No mass or mass effect.
2. Sequela from chronic small vessel disease bilaterally.
Radiology Report
EXAMINATION: LUMBAR PUNCTURE (W/ FLUORO) N8 RF SPINE
INDICATION: ___ year old man with Graves, HTN, mild cognitive impairment p/w
c/f HSV encephalitis. Family requesting single attempt and bedside would be
very difficult.// Would very much appreciate LP
TECHNIQUE: After informed consent was obtained from the patient explaining
the risks, benefits, and alternatives to the procedure, the patient was laid
in prone position on the fluoroscopic table. A pre-procedure time-out was
performed confirming the patient's identity, relevant history, procedure to be
performed and labs.
Puncture was performed at L4-5.
Approximately 5 cc of 1% lidocaine was administered for local anesthesia.
Under fluoroscopic guidance, a 20 gauge, 3.5 inch spinal needle was inserted
into the thecal sac. There was good return of clear CSF. 14 mls of CSF were
collected in 4 tubes and sent for requested analysis.
COMPARISON: None.
FINDINGS:
14 mls of CSF were collected in 4 tubes.
The patient tolerated the procedure well.
Upon completion of the procedure a small 2 x 3 cm hematoma at the site of the
puncture was identified. Appropriate hemostasis was achieved with manual
compression for 5 minutes. The site of the hematoma was supple and without
evidence of hematoma reaccumulation.
The extent of the hematoma was marked and a compression dressing was applied.
IMPRESSION:
1. Successful lumbar puncture at L4-5 without complication.
2. Small hematoma at the site of the puncture with appropriate hemostasis
achieved after manual compression for 5 minutes. The hematoma site was
marked. Findings were discussed with Dr. ___ via telephone on
___ at 17:00 pm and instructions for postprocedure puncture site check
within the next hour was requested.
I, Dr. ___ supervised the trainee during the key components
of the above procedure and I reviewed and agree with the trainee's findings
and dictation.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man p/w facial rash and AMS.// Please eval for PNA
COMPARISON: None
FINDINGS:
AP portable semi upright view of the chest. Patient's chin obscures the
superior mediastinum and portions of the lung apices. Lung volumes are low.
Allowing for limitations, the lungs appear clear. The heart appears mildly
enlarged. No large effusion or definite pneumothorax. No signs of congestion
or edema. Bony structures are intact
IMPRESSION:
No signs of pneumonia on this limited exam. Cardiomegaly.
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST T___ MR HEAD
INDICATION: ___ year old man with Graves, HTN, mild cog impairment p/w facial
rash (? VZV), headaches, and encephalopathy.// Please evaluate for evidence of
encephalitis.
TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After
administration of intravenous contrast, axial imaging was performed with
gradient echo, FLAIR, diffusion, and T1 technique. Sagittal MPRAGE imaging was
performed and re-formatted in axial and coronal orientations.
COMPARISON: CT head from ___ and ___. CTA of the head and
neck from ___.
FINDINGS:
There is no evidence of hemorrhage, edema, masses, mass effect, midline shift
or infarction.
There is a tiny punctate focus of susceptibility artifact in the left inferior
cerebellar hemisphere (series 6, image 2) which may be artifactual or
represent a tiny microhemorrhage.
There are extensive confluent periventricular T2/FLAIR hyperintensities in the
cerebral hemispheres bilaterally and in the pons, nonspecific but suggestive
of extensive chronic small vessel ischemic changes. There is a tiny old
lacunar infarct in the left anterior corona radiata.
There is abnormal enhancement of the left trigeminal nerve within Meckel's
cave (series 1001, image 74), which may be reflective of clinical history
herpes zoster. Correlation with affected side is recommended. There is also
minimal dural thickening enhancement within the internal auditory canals,
nonspecific, and could be reflective of recent lumbar puncture and
intracranial hypotension.
There is no other abnormal enhancement after contrast administration.
There is diffuse generalized parenchymal volume loss, most likely age related.
Prominence of the ventricular system and extra-axial CSF spaces is unchanged
and consistent with the previously mentioned parenchymal volume loss.
Major vascular flow voids appear preserved. Major dural venous sinuses are
patent.
There is mild mucosal thickening in the left frontal sinus and along the
ethmoid air cells with a small mucosal retention cyst in the left maxillary
sinus. The mastoid air cells appear clear. Note is made of bilateral lens
replacement surgery. The orbits appear otherwise unremarkable.
IMPRESSION:
1. No evidence of acute infarction, hemorrhage or intracranial mass. There is
mild enhancement of the left trigeminal nerve within Meckel's cave,
potentially reflective of herpes zoster. There is also suggestion of mild
nonspecific dural thickening along the internal auditory canals, potentially
representative of lumbar puncture sequela, although infectious process not
entirely excluded. No other abnormal intracranial enhancement.
2. Extensive white matter changes in the cerebral hemispheres bilaterally and
in the pons, likely sequela of chronic small vessel ischemic changes. Small
punctate infarct in the left anterior corona radiata.
3. Additional findings described above.
Radiology Report
EXAMINATION: CTA HEAD AND CTA NECK Q16 CT NECK
INDICATION: ___ year old man with likely herpes encephalitis, new seizure
activity// pls eval for new intracranial pathology, stroke
TECHNIQUE: Contiguous MDCT axial images were obtained through the brain
without contrast material. Subsequently, helically acquired rapid axial
imaging was performed from the aortic arch through the brain during the
infusion of intravenous contrast material. Three-dimensional angiographic
volume rendered, curved reformatted and segmented images were generated on a
dedicated workstation. This report is based on interpretation of all of these
images.
DOSE: Acquisition sequence:
1) Stationary Acquisition 5.0 s, 18.8 cm; CTDIvol = 50.0 mGy (Head) DLP =
940.0 mGy-cm.
2) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 14.6 mGy (Head) DLP = 2.9
mGy-cm.
3) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 14.6 mGy (Head) DLP = 2.9
mGy-cm.
4) Stationary Acquisition 14.6 s, 0.2 cm; CTDIvol = 233.0 mGy (Head) DLP =
46.6 mGy-cm.
5) Spiral Acquisition 6.5 s, 42.4 cm; CTDIvol = 32.7 mGy (Head) DLP =
1,364.4 mGy-cm.
6) Stationary Acquisition 5.0 s, 18.8 cm; CTDIvol = 45.5 mGy (Head) DLP =
855.5 mGy-cm.
Total DLP (Head) = 3,212 mGy-cm.
COMPARISON: CT head from ___
FINDINGS:
CT HEAD WITHOUT CONTRAST:
Initial noncontrast CT Head was limited by motion, and additional repeat CT
was obtained after the CTA portion of the exam, which is slightly limited by
presence of residual IV contrast in the vasculature.
Allowing for these limitations, there is no evidence of obvious
infarction,hemorrhage,edema,ormass.
There are atherosclerotic changes along both carotid siphons and the bilateral
intradural vertebral arteries.
There are confluent periventricular hypodensities, nonspecific but unchanged
and suggestive of chronic small vessel ischemic changes. There is generalized
parenchymal volume loss. Prominence of the ventricular system and extra-axial
CSF spaces is consistent with the previously mentioned parenchymal volume
loss.
There is mild mucosal thickening along the ethmoid air cells with a mucous
retention cyst in the left maxillary sinus. The remainder of the paranasal
sinuses is clear. The visualized portion of the mastoid air cells,and middle
ear cavities are clear. Note is made of bilateral lens replacement surgery.
The visualized portion of the orbits are unremarkable.
CTA HEAD:
There are severe atherosclerotic changes along both carotid siphons partly
resulting in focal moderate stenosis especially along the paraclinoid right
ICA. There are vessel wall irregularities along the anterior circulation
vasculature, consistent with atherosclerotic disease. There appears to be
severe vessel stenosis at the origin of the left anterior temporal artery
(series 8, image 279).
Short-segment atherosclerotic changes along both intradural vertebral arteries
result in mild left and moderate right luminal narrowing. The vertebrobasilar
junction is unremarkable. Mild vessel irregularities along the basilar artery
most likely reflect atherosclerotic change but there is no high-grade
stenosis.
There are additional mild vessel wall irregularities along both PCAs but no
high-grade stenosis or vessel occlusion.
There is otherwise no evidence of vessel occlusion or aneurysm formation.
The dural venous sinuses are patent.
CTA NECK:
There is a 3 vessel aortic arch with moderate atherosclerotic changes
extending in to the origin of the great vessels and resulting in mild
narrowing of the right subclavian, left common carotid and left subclavian
arteries. There are atherosclerotic plaques at the origin of both vertebral
arteries resulting in at least mild stenosis. There is some remodeling of the
cervical portion of both vertebral arteries due to hypertrophic degenerative
changes of the cervical spine.
There are mixed atheromatous and atherosclerotic changes at the left carotid
bifurcation resulting in less than 20% luminal narrowing by NASCET criteria
and mild stenosis at the origin of the left external carotid artery. There
are severe atherosclerotic changes at the right carotid bifurcation resulting
in short segment 60-70% stenosis of the proximal right ICA and mild stenosis
at the origin of the right external carotid artery.
OTHER:
There is gravity dependent atelectasis. No suspicious pulmonary nodules. The
visualized portion of the thyroid gland is within normal limits. There is no
lymphadenopathy by CT size criteria. Thin note is made of scalp edema. There
is diffuse cutaneous thickening overlying the left face, potentially
representing clinical suspicion herpes zoster.
IMPRESSION:
1. The initial CT head is limited by motion and a repeat CT head is limited by
the presence of IV contrast. Allowing for this limitation, there is no
obvious acute infarction, hemorrhage or intracranial mass.
2. Diffuse periventricular hypodensities are nonspecific but unchanged and
suggestive of chronic small vessel ischemic changes.
3. Focal 60-70% stenosis of the proximal right ICA and less than 20% focal
stenosis at the origin of the left ICA. Mild stenosis at the origin of both
external carotid arteries.
4. Severe stenosis at the origin of the left anterior temporal artery.
Otherwise diffuse mild vessel irregularities throughout the intracranial
vasculature without high-grade stenosis, occlusion or aneurysm formation.
5. Diffuse atherosclerotic changes of the cervical vasculature resulting in
mild stenosis at the origin of the great vessels and bilateral vertebral
arteries. No evidence of dissection.
6. Additional findings as described above.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with encephalopathy with worsening mental status
and increasing WBC. Please eval for infiltrate// Please evaluate for
infiltrate. Please evaluate for infiltrate.
IMPRESSION:
Heart size is top-normal. Mediastinum is stable. There are parenchymal
opacities, new in right middle lower lung concerning for pneumonia.
Unchanged. No appreciable pleural effusion. No pneumothorax.
RECOMMENDATION(S): Followup of the patient 4 weeks after completion of
antibiotic therapy for documentation of resolution of right lung opacities.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with dysphagia s/p NG tube placement// Assess NG
tube placement
TECHNIQUE: AP portable chest radiograph
COMPARISON: ___
FINDINGS:
The tip of the nasogastric tube projects over the stomach. The lung bases
demonstrate mild atelectasis. Air-filled loops of colon are seen over the
upper abdomen.
IMPRESSION:
The tip of the nasogastric tube projects over the stomach.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with dobhoff NG tube placement// Assess for
appropriate placement.
TECHNIQUE: AP portable chest radiograph
COMPARISON: ___
FINDINGS:
The tip of the Dobhoff projects over the stomach. There is no focal
consolidation, pleural effusion or pneumothorax identified. The size of the
cardiomediastinal silhouette is within normal limits. The thoracic aorta is
noted to be tortuous.
IMPRESSION:
The tip of the Dobhoff projects over the stomach.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP) ___
INDICATION: ___ year old man with dobhoff NG tube placement// Assess
appropriate location/placement. Assess appropriate location/placement.
IMPRESSION:
Compared to chest radiographs ___ through ___.
Feeding tube ends in the upper stomach, partially withdrawn from its location
in the mid stomach yesterday.
Lungs grossly clear. Heart size normal. No definite pleural abnormality.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Eye discharge, Herpes zoster
Diagnosed with Zoster ocular disease, unspecified
temperature: 98.6
heartrate: 78.0
resprate: 20.0
o2sat: 96.0
sbp: 170.0
dbp: 82.0
level of pain: 5
level of acuity: 3.0 | ___ years-old male with history of Graves' disease, essential
hypertension, mild cognitive impairment, recent evaluation at
___ ED on ___ for headache and left facial rash discharged
on valacyclovir and gabapentin presenting with progressive
facial rash, eye pain/discharge, and acute on chronic
encephalopathy.
# Goals of care. Given overall poor prognosis, lack of adequate
nutrition, baseline cognitive impairment, and patient's prior
end of life wishes, the patient was transitioned to ___
focused care based. This decision was reached after multiple
discussions with family. We believe this to be consistent with
the expressed wishes of the patient. We removed nonessential
medications, but continued some acute and chronic medications
that, if withdrawn, may cause increased discomfort. Plan is to
discharge to outpatient care facility with hospice. HPC ___,
patient's wife, and other children (sons) are in agreement with
current management and this discharge plan. Morphine and Ativan
PO prescribed for pain and agitation, respectively, per hospice
recommendations.
# Dysphagia and Malnutrition. NG tube was placed multiple times,
but dislodged
repeatedly. Given overall decline family has elected comfort
feeding and CMO. Will NOT replace NG tube for nutritional
purposes based on goals of care. Thiamine, folate, MVI were
initially administered, but discontinued given goals of care.
#Varicella zoster ophthalmicus and encephalitis:
- ID and neurology evaluated patient and helped guide
investigation and management. Planned ___ day IV acyclovir
course, but have transitioned to PO valacyclovir as outpatient.
Had plan for ophthalmology follow up as outpatient, but will
discontinue this referral. Continue eye drops as recommended by
ophthalmology. Warm compresses and Vaseline as needed to gently
soothe or remove crusting. Tylenol can also be continued as
needed for more mild pain.
# Possible Seizure activity:
- Differential diagnosis includes CNS infection versus PRES. No
ongoing seizure activity. Neurology was consulted and
recommended Keppra suppressive therapy. Reduced dose and
transition to PO on discharge.
# Acute encephalopathy: Multifactorial from VZV encephalitis,
PRES, hospital/illness-related delirium, infection associated
metabolic encephalopathy, hyponatremia, progressive or
decompensated cognitive decline with probable dementia,
malnutrition and deconditioning. Manage underlying conditions.
NCHCT without evidence of hemorrhage, mass, territorial infarct.
B12, treponemal Ab, TSH unremarkable. Discontinued gabapentin in
attempt to avoid all sedating medications as possible. Delirium
precautions performed.
# Ecoli UTI > Possible pneumonia: Infection characterized by
leukocytosis and worsened AMS. Blood culture no growth to date.
CXR with possible RLL infiltrate.
Sputum culture not obtained. MRSA swab negative. S/p 3 days of
antibiotic therapy per ID. Patient initially treated with
empiric IV Vancomycin, IV Ceftazidime, and Azithromycin.
# Hypertensive urgency versus emergency:
- SBPs 200s on arrival. Improved, but remained elevated. Planned
to increase antihypertensive medications as tolerated with NG
tube, but this was not accomplished/sustained effectively as
above. EKG and cardiac enzymes without evidence of end-organ
ischemia.
# SVT: Rare. Presumably asymptomatic and related to electrolyte
deficiency. Replaced magnesium. Holding metoprolol on admission
may have been the initial trigger.
# ___: Creatinine increased from baseline 0.8, which was likely
pre-renal azotemia in the setting of poor PO intake. Discontinue
monitoring given GOC.
# Possible ___: Appears patient was previously on Lasix 20mg
daily. TTE ___ revealed normal LV size and function with EF 60%.
Holding Lasix for many days prior to discharge as patient
appeared relatively volume depleted. Monitor closely for volume
overload. IV fluid given.
# Headache. Mostly resolved. Suspect secondary to facial rash
versus accelerated HTN versus encephalitis. NCHCT negative. ESR
minimally elevated at 22, making GCA/vasculitis less likely
despite increased risk. Tylenol PRN.
# Hyponatremia, likely SIADH. Hypovolemic hypernatremia. IV
fluid replacement to be discontinued. Nutrition discontinued as
above.
# Graves disease: TSH 6.8. We continue home methimazole 7.5 mg
PO daily as tolerated.
# Depression: Holding home sertraline.
# BPH: Holding home finasteride for now (avoiding non-essential
meds) |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
ERCP ___
History of Present Illness:
In brief, this patient is a ___ year old s/p DDLT ___ on
cellcept and ___ with multiple recent hospitalization for
fevers presenting with after a fever to 101.3. Pt reports
developing fevers and fatigue at home ___, and subsequently
presented to ___ ED. Pt was discharged from the ED after
labs were found to be normal. Pt continued to have fevers at
home, and ___ had a measured temp to 101.3. Pt denies URI sx,
cough, SOB, abdominal pain, nausea, vomiting, diarrhea, skin
lesions. In the ___ ED, pt was afebrile but slightly
tachycardic at 103. Labs were notable for WBC 7, H/H 10.8/___.7,
Tbili 0.4, AP 118, AST 45 (hemolyzed), Cr 1.8. CXR did not show
evidence of PNA, and RUQ U/S showed no biliary dilatation or
fluid collections, normal vasculature, and normal liver
appearance. Pt was seen by hepatology in the ED, and per
recommendations, pt was started on broad spectrum abc with Vanc
and ___.
This AM, pt's VS were 97.8 106/56 75 20 98%RA. Pt denies
abdominal pain and fevers/chills. He reports only being tired,
and would like to eat.
Past Medical History:
- Cholangitis c/b citrobacter bacteremia in ___
- Cryptogenic cirrhosis s/p transplant ___
- Hiatal hernia
- GERD
- Esophageal dismotility
- Prostate cancer s/p prostatectomy and penile prosthesis
- Depression
- Chronic kidney disease with baseline creatinine 1.3-3.0
- History of pancreatic cyst (monitored with MRCP)
- Hypertension
- Hypertriglyceridemia
Social History:
___
Family History:
No family history of liver disease, diabetes, or premature CAD.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VS: 97.8 106/56 75 20 98%RA
General: elderly gentleman lying comfortably in bed in NAD
HEENT: NC/AT. anicteric sclerae. conjunctiva pink. MMM, no
erythema or exudates. No LAD
CV: normal rate, regular rhythm. III/VI SEM at apex
Lungs: CTAB
Abdomen: soft, non-distended. surgical scars present. some
tenderness to palpation in LLQ. no rebound/guarding. NABS
Ext: wwp. trace edema in ___ b/l
Neuro: CN II-XII intact, strength full throughout
Skin: no rashes or other lesions noted
DISCHARGE PHYSICAL EXAM:
========================
VS: 98 123/56 (106-134/60s-70s) 70s-90s 18 100% RA
General: comfortable in NAD
HEENT: anicteric sclerae. MMM
CV: normal rate, regular rhythm. III/VI SEM at apex
Lungs: CTAB
Abdomen: soft, non-distended. surgical scars present.
non-tender. no rebound/guarding. NABS
Ext: wwp. no edema
Neuro: A&Ox3. moving all extremities.
Skin: no rashes
Pertinent Results:
ADMISSION LABS:
===============
___ 09:00PM BLOOD WBC-7.0 RBC-3.60* Hgb-10.8* Hct-31.7*
MCV-88 MCH-30.0 MCHC-34.1 RDW-14.2 Plt ___
___ 09:00PM BLOOD Neuts-66.2 ___ Monos-6.3 Eos-4.2*
Baso-0.3
___ 09:00PM BLOOD ___ PTT-32.9 ___
___ 09:00PM BLOOD Plt ___
___ 09:00PM BLOOD Glucose-104* UreaN-31* Creat-1.8* Na-137
K-5.6* Cl-100 HCO3-24 AnGap-19
___ 09:00PM BLOOD ALT-26 AST-45* AlkPhos-118 TotBili-0.3
___ 09:00PM BLOOD Albumin-4.2 Calcium-9.5 Phos-3.2
___ 09:23PM BLOOD Lactate-1.2
DISCHARGE LABS:
===============
___ 06:26AM BLOOD WBC-4.5 RBC-3.59* Hgb-10.7* Hct-31.7*
MCV-88 MCH-29.7 MCHC-33.6 RDW-14.0 Plt ___
___ 06:26AM BLOOD Plt ___
___ 06:26AM BLOOD ___ PTT-31.8 ___
___ 06:26AM BLOOD Glucose-190* UreaN-25* Creat-1.6* Na-145
K-3.9 Cl-108 HCO3-25 AnGap-16
___ 06:26AM BLOOD ALT-17 AST-19 AlkPhos-123 TotBili-0.2
___ 06:26AM BLOOD Calcium-9.6 Phos-2.7 Mg-2.1
___ 06:26AM BLOOD rapmycn-4.0*
MICRO:
======
BLOOD CULTURE ___ - Pending
URINE CULTURE ___ - Pending
STUDIES:
========
Chest X-Ray PA and Lateral ___
FINDINGS: PA and lateral views of the chest provided
demonstrate no focal consolidation, effusion or pneumothorax.
The cardiomediastinal silhouette appears normal. Bony
structures are intact. No free air below the right
hemidiaphragm. A catheter is seen projecting over the mid
abdomen in the lateral projection.
IMPRESSION: No signs of pneumonia.
RUQ Ultrasound ___
IMPRESSION:
Normal appearance of the transplanted liver with normal hepatic
vasculature.
ERCP ___
Findings: Esophagus: Limited exam of the esophagus was normal
Stomach: Limited exam of the stomach was normal
Duodenum: Limited exam of the duodenum was normal
Major Papilla: The 3 previously placed plastic biliary stents (2
straight, 1 double pigtail) were found in good position at the
major papilla. The plastic stents were removed using a snare.
Evidence of a previous sphincterotomy was noted at the major
papilla.
Cannulation: Cannulation of the biliary duct was successful and
deep with a balloon using a free-hand technique. Contrast medium
was injected resulting in complete opacification.
Fluoroscopic Interpretation of the Biliary Tree: Scout film
revealed ___ previous biliary stents in place. The bile duct
was deeply cannulated with the balloon. Contrast was injected
and there was brisk flow through the ducts. Contrast extended to
the entire biliary tree. The previous seen smooth stricture of
benign appearance at the biliary anastamosis was significantly
improved. A very slight narrowing remained but there was
excellent flow of contrast and minimal resistance to passage of
the 12mm balloon. No filling defects were identified. The left
and right hepatic ducts and IHD were normal. The biliary tree
was swept with a 9-12mm balloon starting at the bifurcation. Two
stones and a small amount of sludge was removed. Based on the
drastic improvement in the anastamotic narrowing, no stent was
replaced. Excellent bile and contrast drainage was seen
endoscopically and fluoroscopically.
Radiologic interpretation: I supervised the acquisition and
interpretation of the fluoroscopic images. The quality of the
fluoroscopic images was good. The total fluoroscopy time was
3.2mins.
Impression: Scout film revealed ___ previous biliary stents in
place.
The 3 previously placed plastic biliary stents (2 straight, 1
double pigtail) were found in good position at the major
papilla.
The plastic stents were removed using a snare.
Evidence of a previous sphincterotomy was noted at the major
papilla.
The bile duct was deeply cannulated with the balloon. Contrast
was injected and there was brisk flow through the ducts.
Contrast extended to the entire biliary tree.
The previous seen smooth stricture of benign appearance at the
biliary anastamosis was significantly improved.
A very slight narrowing remained but there was excellent flow of
contrast and minimal resistance to passage of the 12mm balloon.
No filling defects were identified.
The left and right hepatic ducts and IHD were normal.
The biliary tree was swept with a 9-12mm balloon starting at the
bifurcation. Two stones and a small amount of sludge was
removed.
Based on the drastic improvement in the anastamotic narrowing,
no stent was replaced.
Excellent bile and contrast drainage was seen endoscopically and
fluoroscopically
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Fish Oil (Omega 3) 1000 mg PO BID
2. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
3. Multivitamins 1 TAB PO DAILY
4. mycophenolate sodium 360 mg Oral BID
5. Polyethylene Glycol 17 g PO DAILY:PRN constipation
6. Sirolimus 1.5 mg PO DAILY
7. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
8. TraMADOL (Ultram) 50 mg PO Q4H:PRN pain
9. Ursodiol 300 mg PO BID
10. Mirtazapine 15 mg PO HS
Discharge Medications:
1. Mirtazapine 15 mg PO HS
2. mycophenolate sodium 360 mg Oral BID
3. Sirolimus 1.5 mg PO DAILY
4. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
5. TraMADOL (Ultram) 50 mg PO Q4H:PRN pain
6. Ursodiol 300 mg PO BID
7. Fish Oil (Omega 3) 1000 mg PO BID
8. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
9. Multivitamins 1 TAB PO DAILY
10. Polyethylene Glycol 17 g PO DAILY:PRN constipation
11. Ciprofloxacin HCl 500 mg PO Q12H Duration: 7 Days
take for 10 days. last day ___
RX *ciprofloxacin [Cipro] 500 mg 1 tablet(s) by mouth twice a
day Disp #*19 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES
# cholangitis
SECONDARY DIAGNOSIS:
# status post liver transplant
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
CHEST RADIOGRAPH PERFORMED ON ___
COMPARISON: Chest CT from ___ and a chest radiograph from ___.
CLINICAL HISTORY: Fever, on immunosuppression after liver transplant,
question pneumonia.
FINDINGS: PA and lateral views of the chest provided demonstrate no focal
consolidation, effusion or pneumothorax. The cardiomediastinal silhouette
appears normal. Bony structures are intact. No free air below the right
hemidiaphragm. A catheter is seen projecting over the mid abdomen in the
lateral projection.
IMPRESSION: No signs of pneumonia.
Radiology Report
HISTORY: Fever in a liver transplant patient.
COMPARISON: Ultrasound from ___.
FINDINGS:
The liver is normal in size and echotexture. There is no focal liver lesion.
The gallbladder is unremarkable and the biliary tree is normal. There is no
ascites. The spleen has normal echotexture and measures 9.3 cm. The imaged
portion of the abdominal aorta is normal.
DOPPLER: Color Doppler and spectral waveform examination of the hepatic
vasculature was performed. The main, right, and left portal veins are patent
with hepatopetal flow and normal waveforms. Appropriate arterial waveforms
are seen in the main hepatic artery, the right hepatic artery, and the left
hepatic artery, with resistive indices of 0.50, 0.58, and 0.63, respectively.
Appropriate flow is seen in the hepatic veins and inferior vena cava. The
splenic vein and the visualized portion of the superior mesenteric vein are
patent.
IMPRESSION:
Normal appearance of the transplanted liver with normal hepatic vasculature.
Gender: M
Race: PORTUGUESE
Arrive by WALK IN
Chief complaint: Fever
Diagnosed with FEVER, UNSPECIFIED
temperature: 99.6
heartrate: 103.0
resprate: 18.0
o2sat: 97.0
sbp: 125.0
dbp: 84.0
level of pain: 7
level of acuity: 3.0 | ___ man who is currently ___ years status post liver
transplant for cryptogenic cirrhosis with recent
hospitalizations for fever of unclear source now admitted for
recurrent fever, presumed biliary source. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
Lyrica
Attending: ___.
Chief Complaint:
malaise, subjective fevers, abdominal pain
Major Surgical or Invasive Procedure:
Dilation and curettage
History of Present Illness:
___ yo ___ s/p uncomplicated D&E at 16weeks on ___ for
trisomy ___. She did well post-operatively with WNL pain and
bleeding which quickly resolved. Yesterday she began to have
malaise, body aches, subjective fevers and lower abdominal
cramping pain. This pain has increased in severity overnight.
Her
discomfort began aftrer sexual intercourse yesterday.
ROS: Denies dysuria, vaginal bleeding, vomiting, diarrhea, sick
contacts, abdominal trauma
Past Medical History:
OBHx: ___, C/S 1005, cerclage ___, D&E x2 for TAB.
-___: TAB x 2 D&E
-___: "miscarriage" - pt states at "6 months", c/b GDMA
-___: SVD, full term, ___, 6lbs 9 oz, no complications
-___: classical C/S, delivered at 25 weeks, PPROM, Tyji, 1 lbs
8
oz
-___: classical C/S, delivered at 25 weeks, cervical
insufficiency, cerclage, states she had infection and emergency
c/s, Cibreena, 1 lbs 5.8 oz.
-___: TAB
GynHx:hx of Chlamydia, HPV, trich; hx of abnl Paps.
PMH: migraines, depression, anxiety, seasonal allergies.
PSH: classical CSx2, cerclage x1, D&Ex2, thumb surgery,
Family History:
noncontributory
Physical Exam:
On initial evaluation:
General: Appears uncomfortable
Cardiac: RRR
Pulm: CTA
Back: No CVAT
Abdomen: soft, TTP R and LLQ. +voluntary guarding
SSE: normal external anatomy, pink vaginal mucosa, closed cervix
with copious clear yellow discharge.
BME: markedly tender uterus and adenexa.
On day of discharge
General: comfortable
CV: RRR
PULM: CTABL
ABD: soft, NT, ND, fundus is firm
No VB
Pertinent Results:
___ 07:20PM BLOOD WBC-21.8*# RBC-4.02* Hgb-13.4 Hct-39.6
MCV-99* MCH-33.4* MCHC-33.8 RDW-13.1 Plt ___
___ 08:40AM BLOOD WBC-5.1# RBC-3.68* Hgb-12.2 Hct-36.5
MCV-99* MCH-33.1* MCHC-33.5 RDW-12.6 Plt ___
___ 03:00PM BLOOD WBC-6.5 RBC-3.81* Hgb-12.8 Hct-38.0
MCV-100* MCH-33.6* MCHC-33.7 RDW-12.7 Plt ___
___ 06:15AM BLOOD WBC-7.9 RBC-3.21* Hgb-10.7* Hct-31.5*
MCV-98 MCH-33.4* MCHC-34.1 RDW-12.5 Plt ___
___ 07:20PM BLOOD Neuts-91.0* Lymphs-6.0* Monos-2.4 Eos-0.3
Baso-0.3
___ 06:40AM BLOOD Neuts-85.1* Lymphs-10.6* Monos-3.5
Eos-0.6 Baso-0.2
___ 08:40AM BLOOD Neuts-70.1* ___ Monos-5.8 Eos-0.6
Baso-0.9
___ 07:20PM BLOOD ___ PTT-29.8 ___
___ 08:40AM BLOOD Glucose-88 UreaN-8 Creat-0.7 Na-138 K-3.8
Cl-105 HCO3-24 AnGap-13
Radiology Report
HISTORY: Lower abdominal pain status post abortion.
COMPARISON: ___ intraoperative ultrasound
FINDINGS:
Transabdominal and transvaginal ultrasound exam were performed, the latter for
better visualization of the endometrium and ovaries.
The uterus measures 12.8 x 6.6 x 7.8 cm. A heterogeneous iso- to hypoechoic
lesion measuring approximately 2.5 x 4.0 cm is seen within the endometrial
canal with multiple anechoic spaces towards the fundus which demonstrate
vascular flow in a somewhat serpiginous configuration. Doppler sonography of
the area demonstrated elevated arterial systolic velocities up to 69
centimeters/second.
Both ovaries are normal. There is no free fluid.
IMPRESSION:
Findings are concerning for vascularized retained products of conception
versus an arterial venous malformation. If an intraoperative procedure is
planned, recommend interventional radiology involvement for evaluation for
possible embolization.
Radiology Report
INDICATION: ___ woman status post D&E on ___, now presents with
acute onset lower abdominal cramping pain. The patient has diffuse tenderness
over the fundus and adnexa on exam. The patient is afebrile, with an elevated
white count of 22.
COMPARISON: Pelvic ultrasound ___.
TECHNIQUE: Multiplanar T1- and T2-weighted MR images of the pelvis were
performed prior to and after uneventful intravenous administration of 8 mL of
Gadovist.
FINDINGS: The uterus is anteverted and mildly enlarged, measuring 14.0 x 7.0
x 8.8 cm. The endometrial cavity is distended by small amount of blood
products, as well as enhancing soft tissue along the right lateral uterine
body and fundus (2602:35), measuring approximately 3.5 x 1.9 cm, consistent
with vascularized retained products of conception. No enlarged flow voids are
seen within the myometrium to suggest an arteriovenous malformation. The
adnexa are unremarkable, except for a 3-cm left ovarian follicular cyst. No
pelvic lymphadenopathy or free fluid is seen. No pelvic abscess is seen.
The imaged portion of liver, spleen, adrenal glands, kidneys and pancreas are
unremarkable, except to note mild periportal edema as well as trace
perihepatic/retroperitoneal edema, likely related to third spacing from fluid
overload. No pathologic retroperitoneal or mesenteric lymphadenopathy is
seen. The abdominal aorta is normal in caliber. The stomach, small and large
bowel loops, including the appendix are normal.
No marrow signal abnormality is evident.
IMPRESSION:
1. Enhancing soft tissue along the right lateral uterine body and fundus,
associatd with some blood products, consistent with retained products of
conception. Lack of flow voids, makes AVM unlikely.
2. 3-cm left ovarian follicular cyst.
3. No evidence for acute appendicitis.
4. Periportal/retroperioneal edema likely relate to third spacing.
Radiology Report
HISTORY: ___ woman with likely retained products of
conception status post D & E on ___.
COMPARISON: ___
TECHNIQUE: Grayscale and color Doppler ultrasound images were performed.
FINDINGS:
Ultrasound guidance for D&C was performed. Blood and other debris is seen
within the cavity at the end of the procedure.
IMPRESSION:
Ultrasound guidance for D&C.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: ABD PAIN
Diagnosed with ABDOMINAL PAIN OTHER SPECIED, FEVER, UNSPECIFIED
temperature: 96.6
heartrate: 76.0
resprate: 18.0
o2sat: 100.0
sbp: 123.0
dbp: 59.0
level of pain: 10
level of acuity: 3.0 | On ___, Ms. ___ was admitted to the gynecology
service after undergoing dilation and curettage. Please see the
operative report for full details.
Her post-operative course was uncomplicated. Immediately
post-op, her pain was controlled with IV tylenol and dilaudid.
On post-operative day 1, her uterine foley was removed and her
bleeding was minimal. Her urine output was adequate so her foley
was removed and she voided spontaneously. Her diet was advanced
without difficulty and she was transitioned to tylenol.
By post-operative day 1, she was tolerating a regular diet,
voiding spontaneously, ambulating independently, and pain was
controlled with oral medications. She was then discharged home
in stable condition with outpatient follow-up scheduled. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Hydrochlorothiazide / Lipitor / Ultram
Attending: ___.
Chief Complaint:
dizziness and fall
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with hx of AAA, HTN, asymptomatic bradycardia, who presents
s/p presyncope and fall. The pt states she was out shopping and
got groceries. She brought them home and when she bent over to
pick them up, she became dizzy and fell, striking of left face
and L side. She denies LOC. She states she sat on the floor for
2minutes until her husband helped her get up. She denies HA,
blurry vision, CP, SOB, weakness. She denies subsequent
dizziness, but did develop a mild HA with facial pain. The pt
has not suffered a fall in the past but has had occasional
dizziness.
Of note, she has chronically elevated BP and was started on
Hydralazine 10mg TID in ___. This was increased to 20mg TID
in ___ however she experienced increased dizziness and
so was titrated back down to 10mg TID with improved symptoms.
Per cards note she was supposed to stop atenolol however per pcp
note she was told to continue. The pt states she thinks she's
still taking this at present. Of note, the pt was also started
on Pravastatin in ___, with a hx of myalgias in the past
with simvastatin. The pt also endorses hx of bradycardia but
states that it has always been asymptomatic.
.
In the ED, initial VS: 96.8 65 ___ FSG 108. The pt
had ekg and labs without acute changes. u/a clean, CXR nl,
pelvis XR nl, head CT nl, spine CT - degenerative changes, left
knee XR - nl. tetanus updated. She was given acetaminophen 650mg
and oxycodone 5mg x1.
.
Currently, the pt is 96 168/69 67 18 100%RA. She endorses some L
facial pain, L sided breast and bony tenderness, but denies
dizziness, HA, sob, blurry vision, weakness.
.
REVIEW OF SYSTEMS:
Denies fever, chills, night sweats, vision changes, rhinorrhea,
congestion, sore throat, cough, shortness of breath, chest pain,
abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR,
melena, hematochezia, dysuria, hematuria.
Past Medical History:
- Hypertension
- Hyperchloseterolemia
- AAA - infra-renal 3.3cm
- GERD
- Left Renal Mass
-> nodular enhancing solid/cystic left renal mass 16x13mm
- Spinal stenosis
-> with symptoms and signs of radicular compression with an MRI
from ___ disclosing severe spinal stenosis at the L4-L5 level,
grade 1 spondylolisthesis of L4 over L5, severe foraminal
stenosis
at L4-L5 and mild-to-moderate stenosis at L3-L4
- degenerative joint disease of ankles and knees secondary to
severe
mechanical alterations w/ Tricompartmental OA of left knee
thyroid nodules
.
Cardiac Risk Factors: (-)Diabetes, (+) Dyslipidemia and
Hypertension
Social History:
___
Family History:
mother died from childbirth
father diabetes
Physical ___:
ON ADMISSION:
VS - 96 168/69 67 18 100%RA.
Orthostatic on standing with HR from 55 --> 90
GENERAL - L facial abrasion, periorbital swelling, but NAD,
pleasant, A&Ox3
HEENT - left facial abrasion, periorbital swelling and
tenderness, L forehead hematoma, PERRLA
NECK - supple, no thyromegaly, no JVD, loud carotid bruits
particularly on the right side
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - ___ systolic murmur
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - 1+ ___ edema, L knee abrasionSKIN - no rashes or
lesions
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout
.
AT DISCHARGE:
VS - AF 96.6 BP 140-168/60-69 ___ 100% RA
exam otherwise unchanged
Pertinent Results:
.
CT HEAD ___: IMPRESSION: No evidence of injury.
.
CT C-spine:1. Moderate degenerative changes including
spondylolisthesis at two sites which is mild and can very likely
be attributed to background degenerative changes, although
ligamentous injuries are difficult to entirely exclude by
imaging. Clinical correlation is advised.
2. Heterogeneous thyroid including a dominant right lobe nodule.
When
clinically appropriate, evaluation with ultrasound is suggested.
3. Vascular calcifications.
.
L KNEE XRAY ___: IMPRESSION: No acute process.
.
Pelvic XR ___
There are mild degenerative changes at the femoroacetabular
joints. Moderate
degenerative changes are seen in the lower lumbar spine with a
possible
transitional vertebral body.
Calcified uterine fibroids are seen
.
CXR ___ no cardiopulmonary abnormalities
.
- prior cath: normal epicardial coronary arteries;
- ECHO ___: (LVEF 70%) There are focal calcifications in the
aortic arch. minimally increased gradient consistent with
minimal aortic valve stenosis. Mild (1+) aortic regurgitation is
seen. Trivial mitral regurgitation is seen. The left ventricular
inflow pattern suggests impaired relaxation. Moderate [2+]
tricuspid regurgitation is seen. mild pulmonary artery systolic
hypertension.
- Asymptomaptic, slowly growing infra-renal AAA measuring 48.1
mm
(was 43 mm in ___ and ___ --> 45 mm in ___ --> 48 mm now).
.
UA ___ negative.
.
ADMISSION LABS:
___ 05:36PM BLOOD WBC-6.0 RBC-4.16* Hgb-11.4* Hct-35.6*
MCV-86 MCH-27.4 MCHC-32.0 RDW-13.8 Plt ___
___ 05:36PM BLOOD ___ PTT-32.4 ___
___ 05:36PM BLOOD Glucose-88 UreaN-19 Creat-1.0 Na-141
K-3.6 Cl-105 HCO3-23 AnGap-17
___ 06:57AM BLOOD Calcium-8.9 Phos-4.4# Mg-1.6
.
DISCHARGE LABS: virtually unchanged
Medications on Admission:
AMLODIPINE - 10 mg Tablet - 1 Tablet(s) by mouth daily
HYDRALAZINE - 10 mg Tablet - 1 Tablet(s) by mouth three times a
day
LISINOPRIL - 40 mg Tablet - one Tablet(s) by mouth daily
OMEPRAZOLE - 20 mg Capsule, Delayed Release(E.C.) - 1 po
Capsule(s) by mouth once a day
PRAVASTATIN 20mg daily
unclear if pt still taking amlodipine. pt believes she is, but
in last PCP note indicates they are holding atenolol.
.
Medications - OTC
ASPIRIN - (Prescribed by Other Provider) - 81 mg Tablet,
Chewable - 1 Tablet(s) by mouth daily
Discharge Medications:
1. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO every six
(6) hours as needed for pain for 10 days.
Disp:*35 Tablet(s)* Refills:*0*
2. oxycodone 5 mg Capsule Sig: 0.5 Capsule PO every six (6)
hours as needed for pain for 10 days: Please use the tylenol
first and then if you continue to have pain take oxycodone.
Oxycodone can make you sleepy.
Disp:*15 Capsule(s)* Refills:*0*
3. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
4. hydralazine 10 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
5. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
6. lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
7. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
8. pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
pre-syncope due to dehydration
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Can walk independently, but uses
walker.
Followup Instructions:
___
Radiology Report
INDICATION: The patient with left knee pain.
TECHNIQUE:
Single frontal radiograph of the chest was obtained.
COMPARISON: Chest CT from ___, frontal and lateral radiographs
from ___.
FINDINGS:
The lungs are clear, the cardiomediastinal silhouette and hila are normal.
There is atherosclerotic calcification of the aorta.
No pneumonia, no pleural effusion and no pneumothorax.
IMPRESSION: No acute cardiothoracic process.
Radiology Report
INDICATION: Patient after trip and fall, left knee pain.
TECHNIQUE: Single frontal view of the pelvis was obtained.
COMPARISON: There are no comparison studies available.
FINDINGS:
There are mild degenerative changes at the femoroacetabular joints. Moderate
degenerative changes are seen in the lower lumbar spine with a possible
transitional vertebral body.
Calcified uterine fibroids are seen.
IMPRESSION: No fracture.
Radiology Report
INDICATION: Patient after trip and fall, left knee pain.
TECHNIQUE:
Three views of the left knee joint were obtained.
COMPARISON: Left knee joint from ___.
FINDINGS:
The patient is status post total left knee arthroplasty. There is no evidence
of hardware loosening, bony or hardware fracture. No knee joint effusion.
IMPRESSION: No acute process.
Radiology Report
HEAD CT
HISTORY: Status post fall. Question head injury.
COMPARISONS: None.
TECHNIQUE: Non-contrast head CT.
FINDINGS: There is no mass effect, hydrocephalus or shift of the normally
midline structures. The ventricles, cisterns and sulci are unremarkable
without effacement. Patchy calcifications are noted in each basal ganglia. A
small focus of hypodensity in the anterior limb of the left internal capsule
as well as more vague hypodensity along the more anterior part of the internal
capsule suggests chronic small vessel ischemic disease, which is also apparent
in periventricular regions of white matter posterior to the lateral ventricles
in the parietal regions. Surrounding soft tissue structures are unremarkable.
There is no evidence for fracture. Minimal polypoid thickening is noted along
the floor of the left maxillary sinus.
IMPRESSION: No evidence of injury.
Radiology Report
CT OF THE CERVICAL SPINE
HISTORY: Status post fall with head and neck pain.
COMPARISONS: None.
TECHNIQUE: Multidetector CT images of the cervical spine were obtained
without intravenous contrast. Sagittal and coronal reformations were also
performed.
FINDNIGS: The entire thyroid appears heterogeneous including a dominant 18 mm
diameter nodule in the right lobe which is hypodense. Calcifications are
prominent along each carotid bulb.
There are moderate degenerative changes throughout the cervical spine which
can probably explain slight spondylolisthesis of C3 on C4 and C4 on C5.
Specifically facet joint degenerative changes are prominent bilaterally from
C2-C3 through C7-T1. At C7-T1 there is again mild spondylolisthesis.
Particularly from C4-C5 through T1-T2 there are small marginal osteophytes and
mild to moderately narrowed interspaces. Also from C3-C4, throughout the
remaining part of the cervical spine and associated with facet and
uncovertebral joint spurring, there is mild to moderate neural foraminal
narrowing that appears most prominent at C4-C5. There is no evidence for
fracture, dislocation or bone destruction.
IMPRESSION:
1. Moderate degenerative changes including spondylolisthesis at two sites
which is mild and can very likely be attributed to background degenerative
changes, although ligamentous injuries are difficult to entirely exclude by
imaging. Clinical correlation is advised.
2. Heterogeneous thyroid including a dominant right lobe nodule. When
clinically appropriate, evaluation with ultrasound is suggested.
3. Vascular calcifications.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: S/P FALL
Diagnosed with JOINT PAIN-SHLDER, HYPERTENSION NOS
temperature: 96.8
heartrate: 65.0
resprate: 24.0
o2sat: 100.0
sbp: 203.0
dbp: 59.0
level of pain: 13
level of acuity: 2.0 | ___ with hx of AAA, HTN, asymptomatic bradycardia, who presents
s/p presyncope and fall.
.
# Presyncope: Felt to be secondary to orthostasis in setting of
decreased PO intake, precipitated by pending over. Pt had not
eaten breakfast that day and was orthostatic on exam. Pt
recently started on hydralazine which could contribute to
orthostasis but she denies taking this medication on day of
admission. Ddx includes neuro-cardiogenic: possible vasovagal
response, possibly positional vertigo component. Vs Cardiogenic:
Given carotid bruit and systolic murmur, with known AS based on
___ echo, both AS and carotid stenosis could have led to
cerebral hypoperfusion and presyncope. However, AS was only
noted to be mild, and this seems like an isolated episode of
pre-syncope with other more likely etiology. ECG was unchanged
from prior without indication of myocardial injury. No events on
tele overnight. Pt should have carotid u/s and TTE as outpatient
pending her goals of care. Trops were negative. DDx includes
infection but low WBC, no fever, UA neg, CXR without infiltrate,
and no other localizing signs. Ddx also includes thyroid-induced
arhythmia (though no evidence of arrhythmia) as pt with known
thyroid nodule and subnormal TSH in ___. However pt
was constipated and bradycardic and this was felt to be
unlikely. Vs neurogenic syncope but pt without loss of motor,
bowel, bladder control, was not amnestic and had no tongue lacs
on exam to indicate possible seizure.
.
# s/p fall: Pt s/p fall on face and left side with abrasions,
bruising and swelling, no evidence of intracranial bleed or
fractures. Evaluated by ___ was able to walk without dizziness
using walker. Pt went home with ___ services. Given standing
tylenol, went home on tylenol and prn oxycodone, low dose.
.
# HTN: pt with chronically elevated HTN, seems to be in
160s-170s on recent visits. Presented with systolic of 200 in
setting of not taking her meds that day. Hydral recently
started, may have contributed to presyncope. Unclear if pt is
still taking atenolol, pcp was contacted. Sent home on home
hydralazine, amlodipine, lisinopril, holding atenolol in setting
of orthostasis for now given inconsistencies in med rec, but pt
will need this to be re-addressed as beta blockade shown to have
mortality benefit in pts with aortic aneurysms.
.
# AAA: Outpatient imaging for ___ was rescheduled as pt was
in the hospital. Continued aspirin, holding atenolol for now see
HTN above.
.
# GERD: continued omeprazole
.
# HL: continued pravastatin, CK nl.
.
Pt was maintained as DNR/DNI.
.
TRANSITIONAL ISSUES
Pt noted to have R carotid bruit, would consider workup with
ultrasound evaluation of carotid flow. Pt also noted to have
II/VI systolic murmur, echo in ___ noted mild aortic stenosis.
In setting of pre-syncope would consider repeat echo should
symptoms persist. |
Name: ___ Unit ___: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: PODIATRY
Allergies:
Cipro / pain medication
Attending: ___.
Chief Complaint:
L foot pain, N/V
Major Surgical or Invasive Procedure:
___: Amputation left ___ digit, left foot debridement
___: Left foot debridement
___: Left foot debridement
History of Present Illness:
This is a ___ y/o woman with PMHx IDDM, PVD s/p multiple digital
amputations, HTN, HLD presents with polyuria, polydypsia,
nausea, and vomiting ___ weeks and left foot infection. She
reports she stopped taking her insulin approximately 1 week ago.
Complaining of CP, ___ SOB. Reports worsening foot discharge and
pain starting about ___ weeks ago. Also has significant white
thick vaginal discharge. Left foot with foul smell, draining
purulent discharge from ___ toe. Clear wet gangrene. AAOx3
although seems somewhat altered/confused. Crying easily and
anxious.
In the ED, the patient's VS were 98 104 119/80 20 98% RA. Labs
were notable for VBG: 7.32/___, INR 1.2, WBC 26.7 (84% PMNs),
glucose 660, Lactate 2.7, alk phos 187, K 5.1, HCO3 13, Na 125,
AG 29. Repeat labs pending. Insulin gtt was started at 8U/hr.
She was given Vanc/Zosyn for wet gangrene of the lower
extremities, and ondansetron for nausea. She got 2 L NS. Blood
and urine cultures were drawn EKG with nsr. Foot films w/ read
pending but w/ gas visible and foreign object on prelim read,
CXR negative for acute cardiopulmonary process, LENIs negative
for DVT. Vascular surgery was consulted, and recommended
continuing abx, defer to podiatry since she has followed with
them previously for toe amps of R foot.
She was admitted to the MICU for HHS, wet gangrene, vaginal
yeast infection.
Past Medical History:
--IDDM (does not have regular podiatry or ophtho follow-up)
--HTN
--HL
--Right ___ toe amputation ___ ___
--Right ___ toe amputation ___ ___
--C-sections x2 (___)
Social History:
___
Family History:
Mother and father with DM.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: BP 124/80, HR 100, RR 16, O2 99% on RA
General- ill appearing but not in overt distress
HEENT- ncat, extremely dry mucous membranes, ___ oral thrush,
due to nausea did not examine throat/oropharynx
Neck- hyperdynamic carotid pulsation. ___ JVD.
CV- Tachycardic without murmurs rubs or gallops
Lungs- CTAB. ___ wheezing or ronchi. ___ crackles.
Abdomen- Soft, nontender, nondistended, NABS, ___ organomegaly
GU- not examinedreportedly had thick white vaginal discharge
Ext- ___ peripheral edema. The pedal (pt and dp) pulses are
palpable b/l. Right foot s/p amputation of digits ___. Left foot
with fifth metatarsal lesion on dorsal surface with exposed
subcutaneous ___ visible bone. ___ frank discharge.
Malodorous. Positive crepitus.
Neuro- Alert and oriented times three. Moves all of her
extremities with purpose. Follows commands appropriately.
Strength is ___ in her upper and lower extremities bilaterally.
___ asterixis.
DISCHARGE PHYSICAL EXAM:
VSS, Afebrile
Gen - AAOx3, NAD
Cardio: RRR
Pulm: CTA, ___ respiratory distress
Abdomen: soft, NT, ND
Ext: L foot TMA site skin edges are well opposed with minimal
serosanguinous draiange. Sutures are intact. Plantar incision
shows healthy granular tissue with minimal drainage. The flap
appears well vascularized . The patient is in a bi-valve
dorsiflexory cast.
Pertinent Results:
ADMISSION LABS
___ 03:50PM BLOOD WBC-26.7*# RBC-4.32 Hgb-12.2 Hct-40.0
MCV-93# MCH-28.2 MCHC-30.5* RDW-14.4 Plt ___
___ 03:50PM BLOOD Neuts-84.9* Lymphs-11.7* Monos-2.9 Eos-0
Baso-0.5
___ 03:50PM BLOOD ___ PTT-33.1 ___
___ 03:50PM BLOOD Glucose-660* UreaN-33* Creat-1.9* Na-125*
K-5.0 Cl-83* HCO3-13* AnGap-34*
___ 03:50PM BLOOD ALT-5 AST-9 AlkPhos-187* TotBili-0.5
___ 03:50PM BLOOD Lipase-57
___ 03:50PM BLOOD cTropnT-<0.01
___ 09:40PM BLOOD CK-MB-2 cTropnT-<0.01
___ 03:14AM BLOOD CK-MB-2 cTropnT-<0.01
___ 03:50PM BLOOD Albumin-3.3*
___ 09:40PM BLOOD Calcium-8.0* Phos-1.4*# Mg-2.0
___ 03:50PM BLOOD Osmolal-332*
___ 03:41PM BLOOD ___ Temp-36.6 pO2-34* pCO2-29*
pH-7.32* calTCO2-16* Base XS--9
___ 04:00PM BLOOD Glucose->500 Lactate-2.7* Na-131* K-5.1
Cl-93* calHCO3-14*
___ 09:54PM BLOOD freeCa-1.14
PERTINENT RESULTS:
Final Report
HISTORY: Bilateral gangrene. Evaluate for deep vein
thrombosis.
TECHNIQUE: Duplex Doppler examination was performed on both
lower
extremities.
COMPARISON: None.
FINDINGS: There is normal compression and augmentation of the
common femoral,
superficial femoral and popliteal veins bilaterally. There is
normal flow and
compression seen within the calf veins. Normal respiratory
phasicity seen
within the common femoral veins bilaterally.
IMPRESSION: ___ deep vein thrombosis in the right or left lower
extremity.
The study and the report were reviewed by the staff radiologist.
BILATERAL FOOT FILMS: ___.
HISTORY: ___ female with bilateral gangrene. Question
osteomyelitis.
FINDINGS:
RIGHT FOOT: AP, lateral and oblique views of the right footare
compared to right foot films from ___. There is
evidence of prior resections involving the second through fifth
digits, similar compared to prior. There is ___ new focal area
of osteolysis or periosteal reaction. There is mild soft tissue
swelling without subcutaneous gas or radiopaque foreign body.
Degenerative changes again seen at the hindfoot including
unchanged configuration of the talus and calcaneus which are
severely flattened and dysmorphic.
LEFT FOOT: AP, lateral and oblique views of the left foot. ___
prior. There is a radiopaque foreign body measuring
approximately 4 mm at the lateral plantar soft tissues overlying
the proximal phalanx of the small toe on the left. There is
subcutaneous gas locally and extending to the forefoot dorsally
and on the plantar surface. There is ___ evidence of focal
osteolysis. Joint spaces of the foot are unremarkable.
Degenerative changes are seen in the hindfoot. Plantar and
posterior calcaneal spurs are identified.
IMPRESSION:
1. ___ change in the appearance of the right foot, with multiple
amputations.
2. Radiopaque metallic foreign body in the left foot with
subcutaneous gas as described above. ___ osseous changes, ___
radiographic evidence of
osteomyelitis.
BILATERAL LOWER EXTREMITY DOPPLERS ___
FINDINGS: There is normal compression and augmentation of the
common femoral, superficial femoral and popliteal veins
bilaterally. There is normal flow and compression seen within
the calf veins. Normal respiratory phasicity seen within the
common femoral veins bilaterally.
IMPRESSION: ___ deep vein thrombosis in the right or left lower
extremity.
CXR ___
IMPRESSION:
___ acute cardiopulmonary process. ___ focal consolidation.
Findings
This study was compared to the prior study of ___.
LEFT ATRIUM: Mild ___.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.
LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and
regional/global systolic function (LVEF>55%). Apically displaced
papillary muscle (normal variant). ___ resting LVOT gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal diameter of aorta at the sinus, ascending and arch
levels. ___ 2D or Doppler evidence of distal arch coarctation.
AORTIC VALVE: Normal aortic valve leaflets (3). ___ AS. ___ AR.
MITRAL VALVE: Normal mitral valve leaflets with trivial MR. ___
MVP.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR. Normal PA systolic pressure.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
___ PS. Physiologic PR.
PERICARDIUM: ___ pericardial effusion.
Conclusions
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. The diameters of
aorta at the sinus, ascending and arch levels are normal. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and ___ aortic stenosis or aortic
regurgitation. The mitral valve appears structurally normal with
trivial mitral regurgitation. There is ___ mitral valve prolapse.
The estimated pulmonary artery systolic pressure is normal.
There is ___ pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved regional and global biventricular systolic function.
___ valvular pathology or pathologic flow identified.
___ 6:01 am STOOL CONSISTENCY: WATERY
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
Final Report
HISTORY: Left foot infection, status post amputation of digits
two through
five, now spiking fevers and elevated white count, ? abscess.
TECHNIQUE: Imaging performed at 3 Tesla using an extremity
coil. Routine
protocol.
Multiplanar images with and without contrast.
LEFT ANKLE MRI WITHOUT CONTRAST:
There is marrow edema and enhancement in the shaft of the fifth
metatarsal,
extending beyond the distal edge of these films. Small cysts
and edema at the
base of the first metatarsal medially is thought to reflect
degenerative
change. Otherwise, ___ significant marrow edema is identified.
There is prominent diffuse edema and enhancement in the dorsal
and flexor
musculature extending into the mid foot, beyond the edge of
these images. In
addition, there is a large surgical defect along the plantar
aspect of the
foot.
There is scattered subcutaneous edema.
The tendons about the ankle are intact, allowing for mild
tendinosis in the
distal posterior tibial tendon and a small accessory navicular
ossicle. There
is trace tenosynovitis about the PTT, flexor digitorum, flexor
hallucis, and
peroneal tendons. There is mild degenerative signal in the
distal Achilles
tendon (7:13, 5:11), without discrete tear.
There is trace fluid in the tibiotalar, subtalar, and
talonavicular joints,
without gross effusion. There is expansion and degenerative
signal in the
proximal plantar fascia, with a small inferior calcaneal spur.
Following contrast enhancement, ___ evidence of osteomyelitis or
abscess about
the ankle is identified. ___ obvious abscess in the visualized
portion of the
mid foot.
IMPRESSION:
1. ___ abscess or osteomyelitis is detected about the ankle.
2. Edema in the fifth metatarsal is nonspecific. While this
could represent
postoperative changes, the differential diagnosis does include
osteomyelitis.
This abnormality extends beyond the distal edge of these images.
DISCHARGE LABS:
Medications on Admission:
___: lantus 30 units HS, humalog ___ 81mg qd, lisinopril
5mg', pravastatin 40mg HS
Discharge Medications:
1. Piperacillin-Tazobactam 4.5 g IV Q8H
2. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
3. Glargine 42 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
4. Lisinopril 5 mg PO DAILY
5. Aspirin 81 mg PO DAILY
6. Pravastatin 40 mg PO HS
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Wet gangrene, diabetic foot infection, left foot
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Followup Instructions:
___
Radiology Report
HISTORY: Bilateral gangrene. Evaluate for deep vein thrombosis.
TECHNIQUE: Duplex Doppler examination was performed on both lower
extremities.
COMPARISON: None.
FINDINGS: There is normal compression and augmentation of the common femoral,
superficial femoral and popliteal veins bilaterally. There is normal flow and
compression seen within the calf veins. Normal respiratory phasicity seen
within the common femoral veins bilaterally.
IMPRESSION: No deep vein thrombosis in the right or left lower extremity.
Radiology Report
HISTORY: ___ female with diabetic ketoacidosis.
COMPARISON: ___.
FINDINGS:
Single portable view of the chest. Relatively low lung volumes are seen. The
lungs however are clear. The cardiomediastinal silhouette is within normal
limits. No acute osseous abnormality is detected.
IMPRESSION:
No acute cardiopulmonary process. No focal consolidation.
Radiology Report
BILATERAL FOOT FILMS: ___.
HISTORY: ___ female with bilateral gangrene. Question osteomyelitis.
FINDINGS:
RIGHT FOOT: AP, lateral and oblique views of the right footare compared to
right foot films from ___. There is evidence of prior resections
involving the second through fifth digits, similar compared to prior. There
is no new focal area of osteolysis or periosteal reaction. There is mild soft
tissue swelling without subcutaneous gas or radiopaque foreign body.
Degenerative changes again seen at the hindfoot including unchanged
configuration of the talus and calcaneus which are severely flattened and
dysmorphic.
LEFT FOOT: AP, lateral and oblique views of the left foot. No prior. There
is a radiopaque foreign body measuring approximately 4 mm at the lateral
plantar soft tissues overlying the proximal phalanx of the small toe on the
left. There is subcutaneous gas locally and extending to the forefoot
dorsally and on the plantar surface. There is no evidence of focal
osteolysis. Joint spaces of the foot are unremarkable. Degenerative changes
are seen in the hindfoot. Plantar and posterior calcaneal spurs are
identified.
IMPRESSION:
1. No change in the appearance of the right foot, with multiple amputations.
2. Radiopaque metallic foreign body in the left foot with subcutaneous gas as
described above. No osseous changes, no radiographic evidence of
osteomyelitis.
Findings were discussed with Dr. ___ the phone at 8:50 p.m. at the time
of interpretation.
Radiology Report
HISTORY: Abscess and cellulitis left forefoot, status post amputation.
TECHNIQUE: Left forefoot three views obtained portably.
COMPARISON: Left foot radiographs from ___.
Compared with that time, the patient has undergone amputation of the second
through fifth rays, with successive resection of distal portions of the
metatarsals, most extensive at the fifth metatarsal. Subcutaneous emphysema
and skin defect are consistent with recent surgery. Some residual
subcutaneous emphysema along the plantar aspect of the mid foot is also seen.
Severe background osteopenia is noted. Allowing for the recent surgery, no
area of focal osteolysis is detected. Degenerative changes of the mid foot
and calcaneal enthesophytes again noted.
Radiology Report
HISTORY: Debridement.
FINDINGS: In comparison with the study of ___, there has been apparent
further debridement about the remaining portions of the second through fifth
metatarsals. Further information can be gathered from the operative report.
Radiology Report
HISTORY: Foot debridement with fever.
FINDINGS: Low lung volumes accentuate the transverse diameter of the heart.
No radiographic evidence of vascular congestion, pleural effusion, or acute
focal pneumonia.
Radiology Report
MR EXAMINATION OF THE LEFT FOREFOOT WITH AND WITHOUT INTRAVENOUS CONTRAST
HISTORY: Left foot infection. Status post amputation of the second through
fifth toes. Multiple debridements. Rising white count. Evaluation for
abscess.
TECHNIQUE: Multisequence, multiplanar MR examination of the left foot was
performed both pre- and post-intravenous administration of gadolinium.
Sagittal post-contrast fat sat sequence was performed.
COMPARISON: Radiographs of the left foot performed, ___.
FINDINGS:
There is a large open surgical defect within the lateral aspect of the left
forefoot which contains packing material. There has been amputation of the
second through fifth toes. There has also been partial resection of the
distal third through fifth metatarsals.
There is heterogeneous enhancing marrow edema within the distal aspect of the
partially resected fifth metatarsal (8:4, 12:23, 100:24). There is trace
edema within the distal aspect of the partially resected fourth metatarsal.
There is subchondral cystic change within the base of the first metatarsal at
the first tarsometatarsal joint (8:21), degenerative in etiology. There is
minimal subchondral edema at the calcaneocuboid joint, also likely
degenerative in etiology.
There is prominent enhancing subcutaneous and muscular edema within the dorsal
and plantar aspects of the foot without evidence of a fluid collection and /
or abscess. There has been resection of a large amount of soft tissue from
the lateral aspect of the left mid foot as well as the distal fourth and fifth
metatarsals.
IMPRESSION:
1. No MR evidence of an abscess within the left forefoot.
2. Findings suggestive of osteomyelitis superimposed upon post-surgical
changes within the distal aspect of the partially resected fifth metatarsal.
Trace edema is also present within the partially resected fourth metatarsal.
3. Prominent enhancing subcutaneous and muscular edema throughout the left
forefoot, likely neuropathic in etiology, however an infectious etiology can
not be excluded.
4. Large open surgical defect within the lateral aspect of the forefoot.
5. Degenerative joint disease of the calcaneocuboid and first tarsometatarsal
joints.
Findings discussed with ___ of the surgical team at 8:30 am on ___.
Radiology Report
HISTORY: Left foot infection, status post amputation of digits two through
five, now spiking fevers and elevated white count, ? abscess.
TECHNIQUE: Imaging performed at 3 Tesla using an extremity coil. Routine
protocol.
Multiplanar images with and without contrast.
LEFT ANKLE MRI WITHOUT CONTRAST:
There is marrow edema and enhancement in the shaft of the fifth metatarsal,
extending beyond the distal edge of these films. Small cysts and edema at the
base of the first metatarsal medially is thought to reflect degenerative
change. Otherwise, no significant marrow edema is identified.
There is prominent diffuse edema and enhancement in the dorsal and flexor
musculature extending into the mid foot, beyond the edge of these images. In
addition, there is a large surgical defect along the plantar aspect of the
foot.
There is scattered subcutaneous edema.
The tendons about the ankle are intact, allowing for mild tendinosis in the
distal posterior tibial tendon and a small accessory navicular ossicle. There
is trace tenosynovitis about the PTT, flexor digitorum, flexor hallucis, and
peroneal tendons. There is mild degenerative signal in the distal Achilles
tendon (7:13, 5:11), without discrete tear.
There is trace fluid in the tibiotalar, subtalar, and talonavicular joints,
without gross effusion. There is expansion and degenerative signal in the
proximal plantar fascia, with a small inferior calcaneal spur.
Following contrast enhancement, no evidence of osteomyelitis or abscess about
the ankle is identified. No obvious abscess in the visualized portion of the
mid foot.
IMPRESSION:
1. No abscess or osteomyelitis is detected about the ankle.
2. Edema in the fifth metatarsal is nonspecific. While this could represent
postoperative changes, the differential diagnosis does include osteomyelitis.
This abnormality extends beyond the distal edge of these images.
Radiology Report
PORTABLE AP CHEST X-RAY
INDICATION: New PICC line.
COMPARISON: ___ through ___.
FINDINGS:
New right-sided PICC line crosses the midline and goes into the mid left
subclavian vein. Mild cardiac enlargement is unchanged. The lungs are
otherwise clear. There is no pleural effusion or pneumothorax.
CONCLUSION:
Right-sided PICC line crosses the midline and ends in the left subclavian
vein.
This was discussed with ___, IV nurse, at the time of the finding at 9:30
a.m.
Radiology Report
PICC LINE EXCHANGE
INDICATION: Malposition of indwelling PICC line.
The procedure was explained to the patient. A timeout was performed.
RADIOLOGIST: Dr. ___ performed the procedure.
TECHNIQUE: Using sterile technique and local anesthesia, a guidewire was
advanced through the indwelling right arm PICC line which was in the left
brachiocephalic vein, and subsequently into the SVC under fluoroscopic
guidance. The old PICC line was then removed and a peel-away sheath was then
placed over the guidewire. A new 4 ___ single-lumen PICC line measuring 43
cm in length was then placed through the peel-away sheath with its tip
positioned in the SVC under fluoroscopic guidance. Position of the catheter
was confirmed by a fluoroscopic spot film of the chest.
The peel-away sheath and guidewire were then removed. The catheter was
secured to the skin, flushed, and a sterile dressing applied.
The patient tolerated the procedure well. There were no immediate
complications.
IMPRESSION: Uncomplicated fluoroscopically guided PICC line exchange for a
new 4 ___ single-lumen PICC line. Final internal length is 43 cm, with the
tip positioned in the SVC. The line is ready to use.
Radiology Report
AP CHEST, 8:36 A.M. ON ___
HISTORY: ___ woman with a new PICC line.
IMPRESSION: AP chest compared to ___:
Right PICC line has been withdrawn and repositioned now in the upper SVC.
Moderate cardiomegaly stable. Lungs clear. No pleural abnormality.
Radiology Report
HISTORY: Resection.
FINDINGS: In comparison with study of ___, there has been extensive
resections with only portions of the metatarsals remaining. No acute
abnormality is appreciated. Overlying cast somewhat obscures detail.
Gender: F
Race: OTHER
Arrive by WALK IN
Chief complaint: N/V
Diagnosed with NAUSEA WITH VOMITING, DIABETES UNCOMPL ADULT
temperature: 98.0
heartrate: 104.0
resprate: 20.0
o2sat: 98.0
sbp: 119.0
dbp: 80.0
level of pain: 8
level of acuity: 1.0 | The patient is a ___ year old female with a history of insulin
dependent DM, PVD s/p multiple pedal digital amputations, HTN,
and HLD who presented with DKA (has resolved), wet gangrene of
the LLE, and yeast infection, transferred from the MICU to the
medicine floor for management and then was transferred to the
podiatry service for further care.
# Anion Gap/DKA: Likely related to gangrene and medication
non-compliance x 1 week. EKG without evidence of ischemia, trop
<0.01 X3. Pt started on insulin drip at 8 units/hour, with Q2H
lab checks and Q1H FSBGs. Drip was continued through surgery. Pt
was fluid resuscitated w/ NS @ 20 cc/kg/hr, and K was repleted
___ mEQs per L IVF. Once blood glucose was <200, IVF changed
to ___ NS. Gap closed overnight, pt started on 15 units
lantus (half home dose, given pt's PO intake low ___ nausea).
Insulin drip shut off at 8:30 am on HD1, 2.5 hours after
glargine administered. Pt taking po. Nausea controlled w/
zofran. Pt's FSBS remained in 200s over HD 1, lantus and ISS
increased. Pt's gap remained closed and she was called out the
floor in stable condition. ___ came by and gave
recommendations about insulin sliding scale throughout her
admission. They have scheduled her to take 43 units of lantus
qhs and have an insulin sliding scale. She should follow up with
___ as an outpatient.
# Severe Sepsis. Leukocytosis to 26.7 with tachycardia, elevated
lactate. Likely source, wet gangrene of L foot. Vanc/zosyn
started, blood cultures and urine cultures drawn. Chest X-ray
with ___ acute process. Pt taken to OR for amputation of L ___
metatarsal (see Wet gangrene, below) on ___, source control
presumably obtained. Clindamycin added for better clostridium/GN
coverage. Leukocytosis was persistently elevated, but eventually
downtrended and stabilized at 14. She was taken for OR
debridements on ___ and ___ and ___. Of note, her serum Hct
dropped to 18 during her hospital stay and she was transfused
pRBCs on ___ and ___. The medicine team followed along
and determined it was anemia of chronic disease of unknown
etiology.
# Wet gangrene on RLE: Pt has had multiple toe amputations
before and even had osteomyelitis in ___, Related to poorly
controlled DM, peripheral neuropathy and poor foot care (pt
walks around barefoot at times). Foot Xray showing radiopaque
metallic foreign body in the left foot with subcutaneous gas as
described above. Podiatry and ID were involved in her care. This
infection was likely polymicrobial and she was initially covered
with broad spectrum IV antibiotics (vanc to cover MRSA, zosyn to
cover anaerobres and gram neg, clinda to cover C perfringes a
common cause of gas gangrene). Antibiotics were transitioned to
zosyn only per Infectious Disease and culture date only growning
back Group B Strep. She is s/p amputation of L 5 toe ___,
had another debridement on ___ in which toes 2,3,4 were
amputated and another debridement on ___ in which an incision
was also made plantarly to help drain a pocket of purulance that
was traveling along th elong extensor tendon. A wound vac was
placed on ___ after allowing adequate time for drainage, and
was changed on ___. The plantar flap is well granulated at this
time and her WBC count and HCT have responded favorly. Patient
was taken back to the operating room on ___ for a TMA
completion, and tendo achilles lengthening. For full details of
this operation please see operative note. The patient tolerated
the procedure and the genral anesthesia well with ___
complications. Of note, the patients plantar incision was not
closed to allow for additional drainage. The TMA flap was closed
and appeared healthy at time of discharge. The plantar incision
is packed open and changed daily. A bilvalve dorsiflexory cast
was put on patient, and she should remain non-weight bearing to
the LLE with this device in place at all times. The patient
started a 6 week course of IV Zosyn per ID recs and has
completed 3 of the 6 weeks while in house. She should therefore
complete an additional 3 weeks, and plan on terminating
antibiotic treatment on ___. Patient should call their
office to schedule an outpatient follow up appointment.
# Odynophagia/yeast infection: Given diabetes, throat pain and
?odynophagia, possibly candidal esophagitis. Pt started on
fluconazole PO X 2 weeks, and on nystatic swish and swallow and
symptoms resolved and fluconazole was d/c;d after a few doses.
# ___: Likely pre-renal in the setting of DKA and hypovolemia.
Creatinine downtrended over first night of hospitalization as
DKA reversed and pt hydrated. Normalized by HD 1.
#Elevated potassium ___ to 7.0 and then 9.1 but both being
partially hemolyzed specimin. Repeat K drawn from peripheral
stick was 5.7, trended to 5.5 on ___. EKG was negative and
patient was asysmptomatic.
#Chronic diarrhea during hospital admission. C diff negative.
Given h/o chronic diarrhea for past ___ years, should consider
outpatient workup and possible colonoscopy. ___ consider on
next admission.
# INR elevated to 1.2 on presentation. Pt not anticoagulated.
Albumin low at 3.3, so judged likely nutritional.
# HTN: Antihypertensives held due to sepsis. Resumed once
stabilized as needed.
# HLD: cont home medication. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Gold Salts / Penicillins / Remicade / Erythromycin Base /
myochristine / trazodone / naproxen
Attending: ___.
Chief Complaint:
L elbow pain
Major Surgical or Invasive Procedure:
___ ORIF left olecranon fx
History of Present Illness:
Ms. ___ is a ___ RHD-F w/ PMHx of RA s/p multiple joint
replacements who was transferred from ___ after
sustaining a left olecranon fracture after a mechanical fall
yesterday. No HS or LOC. Isolated injury. No numbness or
paresthesias.
Past Medical History:
PAST MEDICAL & SURGICAL HISTORY:
Community Acquired Pneumonia in ___ (RUL, sp cefpodoxime and
azithro)
Rheumatoid arthritis (dx'd ___ prior)
Osteoarthritis
Depression
Cataracts
Cerebral aneurysm, s/p removal ___ yrs ago
Surg Hx:
Cerebral aneurism removal ___ yrs ago
s/p R THR
s/p L shoulder arthroplasty
s/p cerical facet injection
Social History:
___
Family History:
Father died of pneumonia in ___
Mother died of Lung Cancer at age ___.
Physical Exam:
PHYSICAL EXAMINATION in ADM:
Vitals: 98 75 ___ 100%RA
General: Well-appearing female in no acute distress.
Left upper extremity:
- Skin intact
- Scattered ecchymosis and edema, palpable defect at the
olecranon
- Soft, non-tender arm and forearm
- Full, painless ROM at wrist and digits. Unable to extend the
elbow.
- Fires EPL/FPL/DIO
- SILT axillary/radial/median/ulnar nerve distributions
- 2+ radial pulse, WWP
Bilateral lower extremity:
- Skin intact
- No deformity, edema, ecchymosis, erythema, induration
- Soft, non-tender thigh and leg
- Full, painless ROM at hip, knee, and ankle
- Fires ___
- SILT S/S/SP/DP/T distributions
- 1+ ___ pulses, WWP
PE in DC:
AVSS
NAD, A&Ox3
foley in place
LUE:Incision well approximated. Fires EPL/FPL/FDP/FDS/EDC/DIO.
SITLT radial/median/ulnar. 1+ radial pulse, wwp distally.
Pertinent Results:
n/p
Medications on Admission:
ACETAMINOPHEN-CODEINE [TYLENOL-CODEINE #3] - Tylenol-Codeine #3
300 mg-30 mg tablet. ___ tablet(s) by mouth q4hr prn -
(Prescribed by Other Provider)
ACYCLOVIR - acyclovir 400 mg tablet. 1 tablet(s) by mouth bid
for
chronic suppression - (Prescribed by Other Provider)
BUSPIRONE - buspirone 15 mg tablet. 3 tablet(s) by mouth qam, 1
q1pm, q6pm - (Prescribed by Other Provider)
ERGOCALCIFEROL (VITAMIN D2) [VITAMIN D2] - Vitamin D2 50,000
unit
capsule. 1 capsule(s) by mouth q2 wks - (Prescribed by Other
Provider)
ESTROGEN - estrogen . 0.25mg patch - (Prescribed by Other
Provider)
GABAPENTIN - gabapentin 300 mg capsule. 3 capsule(s) by mouth
three times a day - (Prescribed by Other Provider)
HYDROCHLOROTHIAZIDE - hydrochlorothiazide 25 mg tablet. 1
tablet(s) by mouth daily - (Prescribed by Other Provider)
HYDROCODONE-ACETAMINOPHEN - hydrocodone 5 mg-acetaminophen 300
mg
tablet. 1 tablet(s) by mouth three times a day - (Prescribed by
Other Provider)
LEUCOVORIN CALCIUM - leucovorin calcium 5 mg tablet. 2 tablet(s)
by mouth once a week - (Prescribed by Other Provider)
LISINOPRIL - lisinopril 5 mg tablet. 1 tablet(s) by mouth -
(Prescribed by Other Provider)
METHOCARBAMOL - methocarbamol 750 mg tablet. 1 tablet(s) by
mouth
2 tab qam, 2 tab at 1pm, 1 tab at 6pm - (Prescribed by Other
Provider)
METHOTREXATE SODIUM - methotrexate sodium 25 mg/mL injection
solution. 25 mg sq once a week - (Prescribed by Other Provider)
METHYLPHENIDATE - methylphenidate ER 10 mg tablet,extended
release. 3 tablet(s) by mouth qam po - (Prescribed by Other
Provider)
METHYLPHENIDATE - methylphenidate 10 mg tablet. 1 tablet(s) by
mouth 1pm daily po for add - (Prescribed by Other Provider)
METHYLPREDNISOLONE - methylprednisolone 4 mg tablet. 1.5
tablet(s) by mouth once a day - (Prescribed by Other Provider)
NABUMETONE - nabumetone 750 mg tablet. 1 tablet(s) by mouth
twice
a day - (Prescribed by Other Provider)
NORTRIPTYLINE - nortriptyline 10 mg capsule. 1 capsule(s) by
mouth at bedtime - (Prescribed by Other Provider)
OMEPRAZOLE - omeprazole 40 mg capsule,delayed release. 1
capsule(s) by mouth twice a day - (Prescribed by Other
Provider)
ONDANSETRON HCL - ondansetron HCl 4 mg tablet. 1 tablet(s) by
mouth tid prn - (Prescribed by Other Provider)
OXYBUTYNIN CHLORIDE - oxybutynin chloride 5 mg tablet. 1
tablet(s) by mouth twice a day - (Prescribed by Other Provider)
POTASSIUM CHLORIDE [KLOR-CON M20] - Klor-Con M20 mEq
tablet,extended release. 1 tablet(s) by mouth once a day -
(Prescribed by Other Provider)
SIMVASTATIN - simvastatin 5 mg tablet. 1 tablet(s) by mouth once
a day - (Prescribed by Other Provider)
TOCILIZUMAB [ACTEMRA] - Actemra 400 mg/20 mL (20 mg/mL)
intravenous solution. 13 ml iv as needed for as directed -
(Prescribed by Other Provider)
TRETINOIN [RETIN-A] - Retin-A 0.025 % topical cream. Apply to
affected areas qpm prn - (Prescribed by Other Provider)
VENLAFAXINE - venlafaxine ER 150 mg capsule,extended release 24
hr. 1 capsule(s) by mouth twice a day - (Prescribed by Other
Provider)
ASPIRIN - aspirin 81 mg chewable tablet. 1 tablet(s) by mouth
daily po as a preventative - (Prescribed by Other Provider)
CALCIUM CARBONATE-VITAMIN D3 [CALTRATE 600 + D] - Caltrate 600 +
D 600 mg (1,500 mg)-800 unit chewable tablet. 1 tablet(s) by
mouth three times a day - (Prescribed by Other Provider)
MULTIVITAMIN - multivitamin capsule. 1 capsule(s) by mouth once
a
day - (Prescribed by Other Provider)
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
3. Docusate Sodium 100 mg PO BID
4. Enoxaparin Sodium 40 mg SC QPM
Start: Today - ___, First Dose: Next Routine Administration
Time
RX *enoxaparin 40 mg/0.4 mL 0.4 ml QPM Disp #*30 Syringe
Refills:*0
5. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN Pain - Moderate
RX *hydromorphone [Dilaudid] 2 mg 1 tablet(s) by mouth every
four (4) hours Disp #*30 Tablet Refills:*0
6. Senna 8.6 mg PO BID
7. Tamsulosin 0.4 mg PO QHS
8. Acyclovir 400 mg PO Q12H
9. Aspirin 81 mg PO DAILY
10. BusPIRone 15 mg PO QPM
11. BusPIRone 45 mg PO QAM
12. Gabapentin 900 mg PO TID
13. Hydrochlorothiazide 25 mg PO DAILY
14. Leucovorin Calcium 10 mg PO 1X/WEEK (WE)
15. Lisinopril 5 mg PO DAILY
16. Methylprednisolone 6 mg PO DAILY
17. Nabumetone 750 mg PO BID
18. Omeprazole 40 mg PO DAILY
19. Oxybutynin 5 mg PO BID
20. Simvastatin 5 mg PO QPM
21. Tretinoin 0.025% Cream 1 Appl TP QHS:PRN itching
22. Venlafaxine XR 150 mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
L olecranon fx
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: ELBOW (AP, LAT AND OBLIQUE) LEFT IN O.R.
INDICATION: Left elbow fracture, ORIF
TECHNIQUE: 5 spot fluoroscopic images obtained in the OR without radiologist
present
Fluoroscopy time: 7.4 seconds.
COMPARISON: Left elbow radiographs ___.
FINDINGS:
The available images show steps related to open reduction internal fixation of
an olecranon fracture. Alignment is improved when compared to the
preoperative study. 2 percutaneous pins and cerclage wires transfix the
fracture site. Please see the operative report for further details.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: L Arm fracture
Diagnosed with Disp fx of olecran pro w/o intartic extn left ulna, init, Unspecified fall, initial encounter
temperature: 98.0
heartrate: 75.0
resprate: 16.0
o2sat: 100.0
sbp: 110.0
dbp: 95.0
level of pain: 6
level of acuity: 3.0 | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have L olecranon fracture and was admitted to the orthopedic
surgery service. The patient was taken to the operating room on
___ for ORIF left olecranon fx, which the patient tolerated
well. For full details of the procedure please see the
separately dictated operative report. The patient was taken from
the OR to the PACU in stable condition and after satisfactory
recovery from anesthesia was transferred to the floor. The
patient was initially given IV fluids and IV pain medications,
and progressed to a regular diet and oral medications by POD#1.
The patient was given ___ antibiotics and
anticoagulation per routine. The patient's home medications were
continued throughout this hospitalization. The patient worked
with ___ who determined that discharge to Rehab was appropriate.
The ___ hospital course was otherwise unremarkable other
than failing to void and receiving a foley which will be
followed up in ___ clinic.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was moving bowels spontaneously. The patient is NWB,
PROMAT in all modes in the LUE , and will be discharged on
Lovenox for DVT prophylaxis. The patient will follow up with Dr.
___ routine & ___ clinic. A thorough discussion
was had with the patient regarding the diagnosis and expected
post-discharge course including reasons to call the office or
return to the hospital, and all questions were answered. The
patient was also given written instructions concerning
precautionary instructions and the appropriate follow-up care.
The patient expressed readiness for discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Latex / amlodipine
Attending: ___
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with history of HCV cirrhosis complicated by ___, s/p liver
txp ___ on tacrolimus, chronic pancreatitis s/p Puestow
procedure in ___, presents with epigastric abdominal pain
radiating to the back as well as right upper quadrant abdominal
pain for the past 2 days.
Per ED record,
"She has associated nausea without vomiting. Some loose stools
but no diarrhea. No blood in the stool. No fevers. Mild
headache.
No chest pain or shortness of breath. She states this feels
similar to her previous episodes of pancreatitis."
In the ED, initial VS were:
99.7 60 107/83 16 100% RA
Exam notable for: not documented
Labs showed:
12.5
5.0 >-----< 142
37.4
ALT: 26 AP: 116 Tbili: 0.6 Alb: 4.7
AST: 24 Lip: 13
144 ___
-----------------< AGap=14
4.0 27 1.3
U/A: unremarkable
Imaging showed:
Abdominal U/S
1. Patent hepatic vasculature.
2. Common bile duct measures 7 mm, previously 9 mm.
Patient received:
___ 23:06 IV Morphine Sulfate 4 mg
___ 23:06 IVF NS 1000 mL
___ 00:32 IV Morphine Sulfate 4 mg
Hepatology was consulted in the ED.
Recommendations:
"Unclear of trigger for pancreatitis. lipase is not elevated but
this may be because of chronic pancreatitis.
-infectious work up
-pain management
-IV fluids
-abdominal ultrasound
-NPO for now"
Transfer VS were:
00:57 5 98 75 144/78 16 96% RA
On arrival to the floor, patient reports that on ___
night
she started having a small amount of abdominal [pain. She
reports
she did not have a lot ot eat this AM, just had some tea and
weight watchers meal (rice and oriental chicken.) She reports
She
had a throbbing pain in the middle of the abdomen associated
with
back pain and nausea. She denies vomiting. She reports some
constipation feeling; she reports her last BM was this AM;
denies
blood in stool or dark black color though reports it looked like
a light color. Denies sick contact, cough, dysuria.
She reports the pain currently is ___. Reports some
occasional pain under the L side of the chest/L breast which she
reports she has not had previously; she reports that sometime
this pain "comes and goes" and has been happening on and off for
the last "few months". She reports it can come at rest but also
occurs with activity. she reports she has not had this pain
since
the day prior to admission.
REVIEW OF SYSTEMS:
10 point ROS reviewed and negative except as per HPI
Past Medical History:
- HCV cirrhosis
- HCC
- Chronic pancreatitis
- GERD
- Anxiety
- Depression
- Superficial thrombophlebitis
- UE DVT
- Lyme disease
PSH:
- OLT ___
- CCY
- Appendectomy
- Tonsillectomy
- Breast reduction
- Puestow procedure in ___, numerous ERCP in past,
transduodenal minor papilla sphincteroplasty ___
Social History:
___
Family History:
Father died of an MI at ___; alcoholic. Two brothers have
coronary artery disease. Other brother died at age ___ of an
arrhythmia. Mother with diabetes, asthma and COPD.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: ___ 98.5 PO 156 / 89 73 20 91 Ra
General: Alert, pleaseant and in NAD. appears comfortable,
talkative and able to provide full history
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL.
Neck: Supple.
CV: Regular rate and rhythm. Normal S1+S2, no murmurs, rubs,
gallops. chest pain non reproducible on palpation of L chest
wall
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, with midline and RUQ surgical scars, appears well
healed. non-distended, bowel sounds hypoactive. no organomegaly,
no rebound or guarding but tender to palpation most notably in
RUQ and epigastrium.
GU: No foley
Ext: Warm, well perfused, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities
DISCHARGE PHYSICAL EXAM
Vitals: 98.6 PO 143 / 79 66 16 96 RA
General: more alert and comfortable this morning, sitting
upright
in bed. nad.
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: good effort. Clear to auscultation bilaterally, no
wheezes, rales, rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, tender to light palpation in the epigastric and
LUQ, non-distended, normoactive bowel sounds, no rebound
tenderness or guarding, no HSM
Ext: 2+ pulses, no clubbing, cyanosis or edema
Pertinent Results:
ADMISSION LABS:
===============
___ 09:11PM BLOOD WBC-5.0 RBC-4.21 Hgb-12.5 Hct-37.4 MCV-89
MCH-29.7 MCHC-33.4 RDW-12.6 RDWSD-40.3 Plt ___
___ 05:35AM BLOOD ___ PTT-32.1 ___
___ 09:11PM BLOOD Glucose-86 UreaN-20 Creat-1.3* Na-144
K-4.0 Cl-103 HCO3-27 AnGap-14
___ 09:11PM BLOOD ALT-26 AST-24 AlkPhos-116* TotBili-0.6
___ 05:35AM BLOOD Albumin-4.5 Calcium-9.0 Phos-4.5 Mg-1.6
___ 05:35AM BLOOD tacroFK-5.5
IMAGING:
========
MRCP ___
IMPRESSION:
1. No evidence of acute pancreatitis.
2. Unchanged mild central intrahepatic biliary ductal
dilatation and common
bile duct prominence which is likely related to post
cholecystectomy state.
3. Additional findings as above.
CXR ___
IMPRESSION:
Lungs are low volume otherwise clear. Heart size is normal.
There is no
pleural effusion. No pneumothorax is seen
KUB ___
IMPRESSION:
Nonspecific gas pattern with an air-fluid level in the left mid
abdomen,
probably representing early ileus. No clear evidence of free
intraperitoneal
air noted.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 20 mg PO QPM
2. Calcium Carbonate 500 mg PO TID
3. Citalopram 10 mg PO DAILY
4. Hyoscyamine 0.125 mg PO TID
5. Maalox/Diphenhydramine/Lidocaine 15 mL PO TID:PRN throat
burning
6. Polyethylene Glycol 17 g PO DAILY:PRN constipation
7. Senna 8.6 mg PO BID:PRN constipation
8. Tacrolimus 1 mg PO Q12H
9. Vitamin D 800 UNIT PO DAILY
10. Carvedilol 25 mg PO BID
11. Esomeprazole 40 mg Other DAILY
12. Viokace (lipase-protease-amylase) 10,440-39,150- 39,150 unit
oral TID
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*60 Capsule Refills:*0
2. OxyCODONE (Immediate Release) 2.5 mg PO Q6H:PRN Pain -
Severe
RX *oxycodone [Oxaydo] 5 mg 0.5 (One half) tablet(s) by mouth
every six (6) hours Disp #*14 Tablet Refills:*0
3. Atorvastatin 20 mg PO QPM
4. Calcium Carbonate 500 mg PO TID
5. Carvedilol 25 mg PO BID
6. Citalopram 10 mg PO DAILY
7. Esomeprazole 40 mg Other DAILY
8. Hyoscyamine 0.125 mg PO TID
9. Maalox/Diphenhydramine/Lidocaine 15 mL PO TID:PRN throat
burning
10. Polyethylene Glycol 17 g PO DAILY:PRN constipation
11. Senna 8.6 mg PO BID:PRN constipation
12. Tacrolimus 1 mg PO Q12H
13. Viokace (lipase-protease-amylase) 10,440-39,150- 39,150
unit oral TID
14. Vitamin D 800 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
==================
1. Chronic Pancreatitis
Secondary Diagnosis:
===================
1. s/p Liver Transplant
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ year old woman with abdominal pain ___ chronic pancreatitis,
also back pain and chest pain// please evaluate for evidence of PNA, pulmonary
edema, atelectasis
TECHNIQUE: Chest PA and lateral
COMPARISON: ___
IMPRESSION:
Lungs are low volume otherwise clear. Heart size is normal. There is no
pleural effusion. No pneumothorax is seen
Radiology Report
INDICATION: ___ year old woman with abdominal pain due to chronic
pancreatitis, also back pain and chest pain. Please evaluate for evidence of
ileus, free air.
TECHNIQUE: Upright and supine abdominal radiograph.
COMPARISON: CT from ___. Radiograph from ___.
FINDINGS:
There are scattered air-filled small and large bowel loops. Gas is noted in
the rectosigmoid. There is an air-fluid level in the left mid abdomen
projecting over the anastomosis. There are no abnormally dilated loops of
large or small bowel.
There is no free intraperitoneal air.
Osseous structures are unremarkable.
Surgical clips and suture material overlie the low abdomen and pelvis.
There are no unexplained soft tissue calcifications or radiopaque foreign
bodies.
IMPRESSION:
Nonspecific gas pattern with an air-fluid level in the left mid abdomen,
probably representing early ileus. No clear evidence of free intraperitoneal
air noted.
Radiology Report
EXAMINATION: MRI ABDOMEN AND PELVIS WITH AND WITHOUT CONTRAST.
INDICATION: ___ year old woman with ___ s/p liver transplant on tacro and
chronic pancreatitis s/p Puestow procedure. p/w severe n/v// evaluate for
pancreatitis
TECHNIQUE: T1- and T2-weighted multiplanar images of the abdomen and pelvis
were acquired in a 1.5 T magnet.
Intravenous contrast: 6 mL Gadavist.
COMPARISON: MRCP ___. CT torso ___.
FINDINGS:
Lower thorax: Mild right greater than left basilar atelectasis. No pleural
effusions.
Liver: Status post liver transplant. There is no focal hepatic lesion. No
evidence of hepatic steatosis.
Biliary: The gallbladder is surgically removed. Common bile duct measures 1
cm which is in keeping with post cholecystectomy state. Mild central
intrahepatic biliary prominent is again likely related to post cholecystectomy
state, unchanged.
Pancreas: There is atrophy of the pancreas. This is unchanged from prior.
The pancreatic duct is not dilated. No focal pancreatic lesion. There is no
peripancreatic edema to suggest pancreatitis.
Spleen: Spleen is intact measuring 12.1 cm. Tiny splenule.
Adrenal Glands: Again demonstrated is nodule scarring adjacent to the lateral
limb of the right adrenal gland. The left adrenal gland is normal
Kidneys: No hydronephrosis or focal renal lesion.
Gastrointestinal Tract: The bowel is normal caliber.
Lymph Nodes: No adenopathy
Vasculature: Aorta and IVC are normal caliber. Portal vein and hepatic veins
are patent.
Osseous and Soft Tissue Structures: No suspicious osseous lesion.
IMPRESSION:
1. No evidence of acute pancreatitis.
2. Unchanged mild central intrahepatic biliary ductal dilatation and common
bile duct prominence which is likely related to post cholecystectomy state.
3. Additional findings as above.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Abd pain
Diagnosed with Epigastric pain
temperature: 99.7
heartrate: 60.0
resprate: 16.0
o2sat: 100.0
sbp: 107.0
dbp: 83.0
level of pain: 10
level of acuity: 3.0 | BRIEF HOSPITAL COURSE
=====================
___ year old female with a past medical history of Hep C and EtOH
cirrhosis, ___ s/p liver transplant (___) on tacrolimus,
history of everolimus pneumonitis, and chronic pancreatitis s/p
Puestow procedure (___) who presented with abdominal pain
consistent with prior flares of chronic pancreatitis.
#Abdominal Pain
#Chronic Pancreatitis: The patient presented with abdominal pain
that per report felt consistent with her prior flares of chronic
pancreatitis. There was no clear precipitating event. On RUQUS
in ED, there was presence of CBD dilation, though this has been
present on prior hospital admissions in ___. Throughout her
hospitalization, she did not have any hyperbilirubinemia,
jaundice, or fever concerning for biliary infection and she is
s/p cholecystectomy. Her infectious workup, including CXR and
KUB, were negative. She was made NPO initially, provided IVF and
IV dilaudid for pain management. MRCP ___ revealed unchanged
mild central
intrahepatic biliary ductal dilatation with no evidence of acute
pancreatitis. Over the next few days, the patient started to
clinically improve with less abdominal pain, and a better
appetite. By the day of discharge, she was able to tolerate PO.
She will be discharged on PO oxycodone 2.5 mg Q6h X 7 days,
given her moderate abdominal pain. She will be followed up by
the transplant coordinator after discharge.
#HCV cirrhosis s/p liver transplant (___): The patient is s/p
liver transplant in ___. She was initially on everolimus,
however this was stopped in ___ after a pneumonitis reaction.
She has been continued subsequently on Tacrolimus. LFTs and
Tacrolimus levels were within normal limits throughout her
hospitalization. She was continued on tacrolimus 1mg PO q12H
CHRONIC ISSUES:
================
#Chest pain: The patient reported intermittent L sided chest
pain for approximately 1 month, that was non radiating. It was
not associated with abdominal pain and was nonreproducible on
exam. EKG on arrival was essentially unchanged from prior
___, though some flattening of T waves in the precordial
leads. She has a significant family history of CAD, but the
patient has not had prior history of MI or cardiac issues. Given
the pleuritic nature of her pain, this was most likely
musculoskeletal. Her pain spontaneously resolved during her
hospitalization. She will be discharged on Atorvastatin, ASA
81mg.
#Headache: The patient had unilateral (right-temporal) headaches
that lasted >24 hours. Ddx included migraine headache as well as
pain secondary to IV morphine. Notably, the patient has had
migraine headaches in the past. After discontinuing her IV
morphine, her pain resolved. She was given IV Reglan 10mg Q6H
PRN which alleviated her symptoms.
#Right hand pain/tingling: The patient endorsed pain and
tingling in her R arm and hand. This is likely due to nerve
compression given that she was lying on her right arm/shoulder
prior to symptom onset, and that this has occurred in the past.
After changing sleep positions and using a hot pack, her
symptoms improved. Of note, she had a negative tinel's and
phalen's sign.
#CKD: Baseline Cr of 1.2-1.5, Cr 1.3 on admission and unchanged
throughout hospitalization.
#GERD:Continued home regimen of Maalox/diphenhydramine/lidocaine
PRN and omeprazole 20mg BID as an inpatient as her home
esomeprazole is not on formulary
#Depression: Continued home citalopram 10 mg PO daily
#Hyperlipidemia: Continued home atorvastatin
======================= |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Codeine
Attending: ___.
Chief Complaint:
fall, question of syncope
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ yo F h/o DM2, HTN, dementia, who presented with an
unwitnessed fall under unclear circumstances at her assisted
living facility.
Patient reportedly fell at her facility on ___. Per her son
she was not herself on ___ and needed help with dressing.
Last night she was noted to be hyperglycemic to the 400s. This
morning she was found after she fell on the floor with blood
from her hand laceration. She was then taken to the ED for
evaluation.
.
The patient reports feeling herself prior to admission. She does
not remember falling. Denies pain and does not believe that she
struck her head. Fall was unwitnessed. She denies chest pain,
palpitations, urinary incontinence, tongue biting. No prior
seizure history.
Of note, patient had a recent admission in ___ for increasing
confusion and difficult to control blood sugars (~ 500s). During
that admission it was felt that her hyperglycemia was likely
related to a dose decrease of her insulin regimen in setting of
poor po intake, however prior to that admission, was having
hyperglycemia. She was not found to have any infections; nl TSH,
and AM cortisol wnl. She was evaluated by ___ who increased
her lantus and her blood sugars improved.
In the ED, initial VS 97.2 92 148/86 16 97% RA. CT of head/spine
negative. CXR normal. EKG noted to have ST changes in
inferior/lateral leads. Finger stick in the 400s and recevied 8
units of regular insulin. Labs notable for a gap of 18, ketones
in urine. pH: 7.48.
Noted to have a laceration on right ___ digit and evaluated by
plastic surgery. Her neurovascular and range of motion were
noted to be intact. Area was sutured and advised xeroform to
distal aspect if some gapping observed. Recommended antibiotics
for seven days. She was given 1 gram of cefazolin. Vs prior to
transfer: 98.2 103 130/68 18 100% RA. Noted to be a heavy
drinker.
Currently, blood sugar is in 200s and patient would like to eat
dinneer. She has no recollection of her events, however is
requesting to drink vodka.
Past Medical History:
1. Type 2 diabetes mellitus - The patient is followed by Dr.
___ at the ___.
2. Status post syncopal episodes/falls
3. Dementia (probable Alzheimer's type)
4. Osteoarthritis
5. Hypertension
6. Depression
7. Anorexia
8. Osteopenia
PAST SURGICAL HISTORY:
1. Status post microdiscectomy - ___
2. Status post left total knee replacement - ___
Social History:
___
Family History:
Non-contributory
Physical Exam:
VS - Temp 98.6F, BP 144/60, HR 94, R 18, O2-sat 97% RA
GENERAL - elderly female, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
RUE with laceration over R. ___ finger with dressing c/d/i.
SKIN - no rashes or lesions
NEURO - awake, A&Ox person, hospital, year but slow to respond.
CNs II-XII grossly intact, muscle strength ___ throughout,
sensation grossly intact throughout
Pertinent Results:
admission labs
___ 09:50AM BLOOD WBC-11.8*# RBC-3.24* Hgb-10.4* Hct-32.1*
MCV-99* MCH-32.0 MCHC-32.4 RDW-13.6 Plt ___
___ 09:50AM BLOOD Neuts-92.6* Lymphs-4.7* Monos-2.5 Eos-0
Baso-0.1
___ 05:45AM BLOOD ___ PTT-24.6* ___
___ 09:50AM BLOOD Glucose-457* UreaN-33* Creat-0.9 Na-135
K-4.7 Cl-95* HCO3-22 AnGap-23*
___ 09:50AM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
___ 05:22PM BLOOD Type-ART pO2-77* pCO2-35 pH-7.48*
calTCO2-27 Base XS-2
.
other pertinent labs:
___ 09:50AM BLOOD cTropnT-<0.01
___ 05:45AM BLOOD CK-MB-4 cTropnT-0.02*
___ 07:00AM BLOOD cTropnT-<0.01
___ 12:36AM BLOOD CK(CPK)-104
___ 05:45AM BLOOD LD(LDH)-153 CK(CPK)-95 TotBili-0.7
___ 07:00AM BLOOD ALT-12 AST-18 AlkPhos-63 TotBili-0.5
___ 05:45AM BLOOD Hapto-185
.
discharge labs
___ 06:40AM BLOOD WBC-5.1 RBC-2.62* Hgb-8.1* Hct-25.6*
MCV-98 MCH-30.8 MCHC-31.5 RDW-13.7 Plt ___
___ 06:30AM BLOOD Glucose-133* UreaN-17 Creat-0.8 Na-141
K-4.1 Cl-103 HCO3-31 AnGap-11
___ 06:30AM BLOOD Calcium-8.9 Phos-4.3 Mg-1.9
.
urine
___ 10:46AM URINE Color-Yellow Appear-Clear Sp ___
___ 10:46AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-1000 Ketone-80 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
.
micro
Blood Culture, Routine (Final ___: NO GROWTH.
.
studies
ECG: ___: Sinus rhythm. Modest inferolateral ST-T wave
changes that are non-specific.
Compared to the previous tracing of ___, there is no
significant diagnostic change.
.
CT head: IMPRESSION: No evidence of acute intracranial process.
.
CT Cspine without contrast: No evidence for acute fracture in
the setting of unchanged severe degenerative changes of the
cervical spine.
.
L. Knee - 3 views
IMPRESSION: No evidence of acute process. Status post left
total knee
replacement.
.
R. hand xray: Degenerative changes and findings which may
reflect prior
inflammation or trauma involving the second and third
metacarpophalangeal
joints. Correlation with localizing findings is recommended,
but there is no definite evidence for fracture.
.
CXR: IMPRESSION: No evidence of acute disease. New mild
elevation of the left hemidiaphragm.
Medications on Admission:
1. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6. Calcium with Vitamin D 600 mg(1,500mg) -400 unit Tablet Sig:
One (1) Tablet PO twice a day.
7. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO three
times a day.
8. insulin glargine 100 unit/mL Solution Sig: 7 units
Subcutaneous at bedtime.
9. Novolog Mix 70-30 100 unit/mL (70-30) Solution Sig: 10 units
Subcutaneous QAM.
Discharge Medications:
1. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. calcium carbonate-vitamin D3 600 mg(1,500mg) -400 unit
Capsule Sig: One (1) Capsule PO twice a day.
6. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain.
7. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. amoxicillin-pot clavulanate 875-125 mg Tablet Sig: One (1)
Tablet PO Q12H (every 12 hours) for 4 days.
Disp:*7 Tablet(s)* Refills:*0*
10. Lantus 100 unit/mL Solution Sig: Fifteen (15) units
Subcutaneous at bedtime.
11. Novolog Mix 70-30 100 unit/mL (70-30) Solution Sig: Fifteen
(15) units Subcutaneous qAM.
Discharge Disposition:
Home With Service
Facility:
___.
Discharge Diagnosis:
primary diagnosis: mechanical fall, hyperglycemia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
CHEST RADIOGRAPH
HISTORY: Status post fall. Question fracture.
COMPARISONS: Scout view from chest CT performed on ___.
TECHNIQUE: Chest, AP supine.
FINDINGS: The heart is normal in size. The aortic arch is calcified. The
mediastinal and hilar contours appear unchanged. The lungs appear clear.
There is no pleural effusion or pneumothorax. Mild relative elevation of the
left hemidiaphragm compared to the right appears new. Prior fractures involve
the posterior seventh and eighth ribs with callus appear incompletely united.
IMPRESSION: No evidence of acute disease. New mild elevation of the left
hemidiaphragm.
Radiology Report
RIGHT HAND RADIOGRAPHS
HISTORY: Status post fall. Question fracture.
COMPARISONS: None.
TECHNIQUE: Left hand, three views.
FINDINGS: Mild degenerative changes are noted at the first carpometacarpal
joint. There are mild-to-moderate degenerative changes involving the first
metacarpophalangeal and interphalangeal joints. The second through fifth
proximal interphalangeal joints show mild degenerative changes and moderate
degenerative change including prominent osteophytes are noted at the second
through fifth distal interphalangeal joints. Degenerative changes are most
prominent at the fifth. The second, fourth and fifth metacarpophalangeal
joints are mildly narrowed. The third appears more severely narrowed with
subluxation and subchondral sclerosis, both likely chronic. There are
chronic-appearing erosive changes along the second and third metatarsal heads
with corticated margins, with suggestion of remodeling of each head; this
appearance may be consistent with remote prior trauma or possibly
inflammation. The possibility of prior inflammatory arthropathy could be
considered in the appropriate clinical setting, however. Vascular
calcifications and demineralization are noted.
IMPRESSION: Degenerative changes and findings which may reflect prior
inflammation or trauma involving the second and third metacarpophalangeal
joints. Correlation with localizing findings is recommended, but there is no
definite evidence for fracture.
Radiology Report
RADIOGRAPHS OF THE LEFT KNEE
HISTORY: Status post fall. Question fracture.
COMPARISONS: ___.
TECHNIQUE: Left knee, three views.
FINDINGS: The patient is status post left total knee replacement. The
femoral and tibial prostheses appear well-seated without evidence for hardware
loosening. There is again a small osteophyte along the superior margin of the
patella. There is no evidence for fracture, dislocation or bone destruction.
Vascular calcifications are present. There has been no significant change.
IMPRESSION: No evidence of acute process. Status post left total knee
replacement.
Radiology Report
INDICATION: Fall, evaluate for fracture or intracranial injury.
COMPARISONS: CT of the head ___.
TECHNIQUE: Continuous axial images were obtained through the brain without
the administration of IV contrast. Coronal, sagittal, and thin slice bone
reconstructed images were provided and reviewed.
FINDINGS: There is no acute hemorrhage, edema, or shift of the normally
midline structures. No large territorial vascular infarction is seen.
Prominence of the ventricles and sulci likely relates to age-related volume
loss. White matter hypodensities, though nonspecific, are compatible with
sequela of chronic small vessel disease. Gray-white matter differentiation is
preserved. The basal cisterns remain patent. The visualized paranasal
sinuses and mastoid air cells are well aerated. As previously mentioned, a
bony projection seen in the left sphenoid sinus may represent an osteoma.
There is no fracture. The lenses and globes are normal.
IMPRESSION: No evidence of acute intracranial process.
Radiology Report
INDICATION: Fall, evaluate for fracture.
COMPARISONS: CT of the cervical spine ___.
TECHNIQUE: MDCT axial images were obtained through the cervical spine without
the administration of IV contrast. Coronal, sagittal and thin section bone
reformations were provided and reviewed.
FINDINGS: There is no fracture. No prevertebral soft tissue swelling or
malalignment is noted. Again seen are severe degenerative changes of the
cervical spine marked by anterior osteophytosis and loss of disc height. This
appears most severe at C4-5 through C6-7. At this level, there is mild canal
stenosis, otherwise, the spinal canal is grossly patent. The visualized lung
apices are unremarkable. The thyroid is normal. Vascular calcifications are
seen at the carotid bifurcations.
IMPRESSION: No evidence for acute fracture in the setting of unchanged severe
degenerative changes of the cervical spine.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: S/P FALL
Diagnosed with SYNCOPE AND COLLAPSE, OPEN WOUND OF FINGER, ACC-CUTTING INSTRUM NEC, SENILE DEMENTIA UNCOMP
temperature: 97.2
heartrate: 92.0
resprate: 16.0
o2sat: 97.0
sbp: 148.0
dbp: 86.0
level of pain: 13
level of acuity: 2.0 | ___ yo F with hx of dementia, diabetes, and recurrent falls who
presented from her assisted living facility s/p unwitnessed fall
found to have right hand laceration, drop in HCT, and elevated
blood sugars.
.
# Fall: patient found s/p unwitnessed fall. Fall may have been
mechanical given baseline unsteady gait (needs walker) and ETOH
use. Patient also may have been orthostatic from frequent
urination due to hyperglycemia and/or ETOH. She has no known
coronary disease and denied chest pain, shortness of breath or
palpitations. However, admission ECG did show some slight ST
depressions in inferior and lateral leads. She had no murmurs on
exam to suggest valvular disease. She has no known seizure
history and there was no evidence of bowel/bladder incontinence
or tongue biting. Patient has had multiple prior workups for
falls that have been unrevealing. Troponins were negative. She
was treated with IVF and evaluated by ___ who felt patient was
safe for discharge back to her assisted living facility.
.
# Hyperglycemia - Patient found to have high finger sticks up to
400s during admission. She was evaluated by the ___ team
during admission and her insulin regimen was ultimately changed
to lantus 15 units qhs and novolog 70/30 15 units qAM. She will
have a ___ to help with insulin administration.
.
# hand laceration - Patient had stitches placed and received a
tetanus shot while in the ED. It was recommended that she
complete a 7 day course of antibiotics (prescribed augmentin).
She was given tylenol as needed for pain. Patient will need to
have stitches removed in 1 week.
# anemia - Patient noted to have HCT drop from 32 to 25. This
may be dilutional given drop in all cell lines vs equilibration
after bleed from laceration. Patient denied any melana or
hematochezia and remained hemodynamically stable. Stool guiac
was negative. Multiple repeat hematocrits remained stable.
Hemolysis labs were negative. No transfusion was required.
# leukocytosis - Differential included trauma from hand injury,
infection, ischemia, stress response. Patient ruled out for MI.
She underwent an infectious workup which was negative. White
count subsequently normalized prior to discharge.
# anion gap metabolic acidosis - Patient initially presented
with metabolic acidosis likely related to ketoacidosis from
hyperglycemia, dehydration/starvation, and etoh. Acidosis
resolved with fluid resuscitation and blood glucose control.
# Alcohol Abuse: Patient given multivitamin, folate, thiamine.
She was placed on an ativan CIWA scale however did not require
this.
# Hypertension: stopped lisinopril as patient normotensive
# Hyperlipidemia: continued lipitor
Transitional Issues:
- patient will need ___ to help with insulin administration
- patient will need stitches removed within 1 week
- patient will need to complete 7 day course of antibiotics
- blood sugars will need to be monitored and insulin regimen may
need further titration |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Cipro / lidocaine / morphine / Sulfa (Sulfonamide Antibiotics) /
lisinopril
Attending: ___.
Major Surgical or Invasive Procedure:
___: Coronary angiography
attach
Pertinent Results:
ADMISSION LABS
===============
___ 04:09PM NEUTS-65.6 LYMPHS-16.8* MONOS-12.0 EOS-4.7
BASOS-0.4 IM ___ AbsNeut-6.58* AbsLymp-1.69 AbsMono-1.20*
AbsEos-0.47 AbsBaso-0.04
___ 04:09PM WBC-10.0 RBC-3.85* HGB-11.9 HCT-37.4 MCV-97
MCH-30.9 MCHC-31.8* RDW-13.7 RDWSD-48.6*
___ 04:09PM ALBUMIN-4.1
___ 04:09PM cTropnT-<0.01
___ 04:09PM LIPASE-63*
___ 04:09PM ALT(SGPT)-15 AST(SGOT)-17 ALK PHOS-94 TOT
BILI-0.3
___ 04:09PM GLUCOSE-95 UREA N-35* CREAT-1.6* SODIUM-139
POTASSIUM-3.8 CHLORIDE-99 TOTAL CO2-27 ANION GAP-13
___ 04:36PM ___ PTT-38.4* ___
___ 04:46PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NORMAL PH-6.0
LEUK-MOD*
___ 04:46PM URINE RBC-3* WBC-7* BACTERIA-FEW* YEAST-NONE
EPI-3 TRANS EPI-<1
___ 08:05PM cTropnT-<0.01
DISCHARGE LABS
===============
___ 07:00AM BLOOD WBC-8.3 RBC-3.39* Hgb-10.5* Hct-33.0*
MCV-97 MCH-31.0 MCHC-31.8* RDW-13.7 RDWSD-48.8* Plt ___
___ 07:00AM BLOOD Glucose-101* UreaN-39* Creat-1.7* Na-139
K-5.2 Cl-96 HCO3-28 AnGap-15
___ 07:00AM BLOOD Calcium-9.3 Phos-4.2 Mg-2.5
OTHER PERTINENT LABS
=====================
___ 08:45AM BLOOD Triglyc-161* HDL-54 CHOL/HD-2.6
LDLcalc-52
PERTINENT IMAGING/REPORTS
==========================
CHEST CT ___: 1. No evidence of pulmonary embolism or acute
thoracic aortic abnormality.
2. Ill-defined, ground-glass opacity within the right upper
lobe, measuring 1.3 cm, is nonspecific and could be infectious
or inflammatory in etiology.
3. Multifocal areas of mucous plugging within the bilateral
lower lobe
airways.
CORONARY ANGIOGRAPHY ___: No angiographically apparent
coronary artery disease.
Widely patent LAD stent.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amiodarone 100 mg PO DAILY
2. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
3. Metoprolol Succinate XL 25 mg PO DAILY
4. Apixaban 2.5 mg PO BID
5. Atorvastatin 40 mg PO QPM
6. Escitalopram Oxalate 10 mg PO DAILY
7. Levothyroxine Sodium 88 mcg PO DAILY
8. Aspirin 81 mg PO DAILY
9. Ferrous Sulfate 325 mg PO DAILY
10. Vitamin D ___ UNIT PO DAILY
11. Furosemide 80 mg PO DAILY
12. Pantoprazole 40 mg PO Q12H
13. Cyanocobalamin 500 mcg PO DAILY
Discharge Medications:
1. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO QID:PRN
belching, GI upset
RX *alum-mag hydroxide-simeth 200 mg-200 mg-20 mg/5 mL ___ ml
by mouth four times a day Disp #*1 Bottle Refills:*0
2. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN SOB
RX *ipratropium-albuterol 0.5 mg-3 mg (2.5 mg base)/3 mL 1 puff
inh three times a day Disp #*3 Ampule Refills:*0
3. Amiodarone 100 mg PO DAILY
4. Apixaban 2.5 mg PO BID
5. Aspirin 81 mg PO DAILY
6. Atorvastatin 40 mg PO QPM
7. Cyanocobalamin 500 mcg PO DAILY
8. Escitalopram Oxalate 10 mg PO DAILY
9. Ferrous Sulfate 325 mg PO DAILY
10. Furosemide 80 mg PO DAILY
11. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
12. Levothyroxine Sodium 88 mcg PO DAILY
13. Metoprolol Succinate XL 25 mg PO DAILY
14. Pantoprazole 40 mg PO Q12H
15. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES
===================
# Chest pain
# Chronic heart failure with preserved ejection fraction
SECONDARY DIAGNOSES
====================
# Atrial fibrillation
# Chronic kidney disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (AP AND LAT)
INDICATION: History: ___ with chest pressure // eval for acute pathology
TECHNIQUE: Upright AP and lateral views of the chest
COMPARISON: None.
FINDINGS:
Heart size is mildly enlarged. The mediastinal and hilar contours are
unremarkable apart from atherosclerotic calcifications at the aortic knob. The
pulmonary vasculature is normal. Lungs are clear. No pleural effusion or
pneumothorax is seen. Eventration of the right hemidiaphragm is incidentally
noted. There are no acute osseous abnormalities. Mild degenerative changes
are noted in the thoracic spine.
IMPRESSION:
No acute cardiopulmonary abnormality.
Radiology Report
EXAMINATION: CTA CHEST WITH CONTRAST
INDICATION: History: ___ with chest pain and back pain // eval for aortic
pathology
TECHNIQUE: Axial multidetector CT images were obtained through the thorax
after the uneventful administration of intravenous contrast. Reformatted
coronal, sagittal, thin slice axial images, and oblique maximal intensity
projection images were submitted to PACS and reviewed.
DOSE: Acquisition sequence:
1) Stationary Acquisition 3.0 s, 0.5 cm; CTDIvol = 18.2 mGy (Body) DLP =
9.1 mGy-cm.
2) Spiral Acquisition 3.4 s, 27.1 cm; CTDIvol = 13.5 mGy (Body) DLP = 366.3
mGy-cm.
Total DLP (Body) = 375 mGy-cm.
COMPARISON: Chest x-ray ___.
FINDINGS:
HEART AND VASCULATURE: Pulmonary vasculature is well opacified to the
subsegmental level without filling defect to indicate a pulmonary embolus. The
thoracic aorta is normal in caliber without evidence of dissection or
intramural hematoma. Moderate coronary artery calcifications. The heart,
pericardium, and great vessels are within normal limits. No pericardial
effusion is seen.
AXILLA, HILA, AND MEDIASTINUM: No axillary or mediastinal lymphadenopathy.
Right hilar lymph node is prominent, measuring up to 11 mm, and may be
reactive. No mediastinal mass.
PLEURAL SPACES: No pleural effusion or pneumothorax.
LUNGS/AIRWAYS: An ill-defined, ground-glass opacity within the right upper
lobe measures 1.3 cm (3:36), nonspecific. Mild dependent atelectasis in both
lower lobes. Multifocal areas of mucous plugging within the bilateral lower
lobes and mild airway wall thickening. Otherwise, the central airways are
patent to the level of the proximal bronchi bilaterally.
BASE OF NECK: Visualized portions of the base of the neck show no abnormality.
ABDOMEN: The study is not tailored for evaluation of the subdiaphragmatic
structures. Within this limitation, a subcentimeter hypodensity within the
spleen is too small to characterize. The remaining imaged upper abdomen is
unremarkable.
BONES: No suspicious osseous abnormality is seen.? There is no acute fracture.
IMPRESSION:
1. No evidence of pulmonary embolism or acute thoracic aortic abnormality.
2. Ill-defined, ground-glass opacity within the right upper lobe, measuring
1.3 cm, is nonspecific and could be infectious or inflammatory in etiology.
3. Multifocal areas of mucous plugging within the bilateral lower lobe
airways.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with history of heart failure s/p cath for
which she received pre hydration. Now worsening dyspnea and crackles on exam.
// Pulmonary edema
TECHNIQUE: Portable chest AP
COMPARISON: Chest radiograph dated ___ chest CT dated ___
FINDINGS:
Low lung volumes. Mild cardiomegaly, unchanged from prior. Minimal evidence
of microvascular engorgement. No pleural effusion or pneumothorax.
Redemonstration of eventration of the right hemidiaphragm.
IMPRESSION:
Minimal microvascular engorgement.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Chest pain
Diagnosed with Chest pain, unspecified
temperature: 98.6
heartrate: 73.0
resprate: 18.0
o2sat: 96.0
sbp: 114.0
dbp: 67.0
level of pain: 10
level of acuity: 2.0 | PATIENT SUMMARY STATEMENT FOR ADMISSION
========================================
Ms. ___ is a ___ female with a history of A. fib on
apixaban, HTN/HLD, CKD (baseline Cr 1.6) CAD status post DES x2
in ___, and heart failure with preserved ejection fraction.
Presented with chest pressure/discomfort concerning for unstable
angina but ruled out CAD on cardiac cath.
TRANSITIONAL ISSUES
=====================
Discharge Cr:1.7
Discharge Hgb: 10.5
Discharge weight: 70.6 kg - 155.64 lbs
[ ] Follow up with GI as an outpatient to consider esophageal
spasms as source of chest pain given responsiveness to nitrates
and negative cath.
[ ] Required IV diuresis s/p cath, but was put back on home
furosemide 80mg daily on discharge
[ ] Continues to have baseline dyspnea. ___ benefit from pulm
follow up.
ACUTE MEDICAL ISSUES ADDRESSED
===============================
# Chest pain
# Unstable angina - ruled out
# Stable CAD
# ? Esophageal spasms
Patient presented with chest pressure/discomfort that radiated
to her back. Troponin was negative and trend was flat and ECG
was normal. Dissection and PE ruled out on CTA. Had history of
CAD requiring PCI with DES x2 in ___. Furthermore, recent
stress test with mild reversible inferolateral perfusion defect.
Patient was admitted with working diagnosis of unstable angina
and underwent cardiac cath with no obstructive CAD and permeable
stents. Given responsiveness to nitrates and history of prior
esophageal pathology main working diagnosis transitioned to
esophageal spasms and therefore it would be useful to consider
GI follow-up as an outpatient. Of note, after cath patient
complained of floaters but remained non-focal after neuro
checks, and also developed minor hematoma that resolved with
applying pressure. After initial presentation patient remained
chest pain free throughout admission.
# Chronic HFpEF
Patient with history of heart failure with preserved ejection
fraction (60-65%). Upon admission patient not in acute
exacerbation. However, throughout admission received IVF as
prehydration for coronary angiography contrast load and
afterwards appeared slightly volume up on exam, endorsed some
DOE and crackles were evident on exam. Received IV Lasix therapy
for 48h hours with overall net negative fluid balance. Main
consideration was that worsening of dyspnea was thought to be
secondary to fluid received in preparation to cath. After IV
diuresis patient with dyspnea close to baseline and was
successfully transitioned back to home oral regimen of
furosemide.
CHRONIC ISSUES PERTINENT TO ADMISSION
======================================
# GERD
The patient had belching, gas, and some epigastric pain. Likely
secondary to GERD.
- Continued PPI BID
- Started on Maalox
# Afib
Chronic atrial fibrillation with CHADS-VASc of 6
- Rhythm control: Continued home amiodarone
- rate control: Continued home metoprolol
- AC: apixaban 2.5 mg BID at home held while on heparin gtt and
restarted after discontinuation
# CKD
Creatine at baseline 1.6. Remained at baseline throughout
admission.
#COPD
- Started on duonebs due to cough and congestion that she can
take PRN at home.
# Iron deficiency anemia
- Continued home iron
# Hypothyroidism
- Continued Home levothyroxine 88mcg daily
CORE MEASURES
===============
# CODE: Full p
# CONTACT: ___ ___ (daughter)) HCP: None listed |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Mercaptopurine Analogues (Thiopurines) / Remicade / Humira /
Cymarin / Dilaudid / Morphine / Erythromycin Base / Halothane /
Mercaptopurine / ciprofloxacin / Zofran (as hydrochloride)
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is a ___ w/ PMH history of ulcerative colitis status
post colectomy with ileal pouch anal anastomosis complicated by
recurrent pouchitis (now on vedolizumab and budesonide), primary
sclerosing cholangitis, recurrent peritoneal inclusion cysts
(s/p ___ drainage ___, who presents with diffuse abdominal
pain, constipation and decreased urinary output.
Patient has a complicated history of chronic pelvic pain, with
recurrent peritoneal inclusion cysts, s/p drainage by ___ several
times in ___ and most recently in ___. Her sxs have only
partially responded to these procedures and she usually has
recurrence of these cysts. She also has a history of voiding
dysfunction (seen by urology in ___, has had urodynamic
studies) and the leading diagnosis is incomplete bladder
emptying due to incomplete pelvic relaxation that improved with
intermittent self catheterization and pelvic ___ in ___.
Finally, regarding her UC, she is s/p colectomy with ileal-anal
anastomosis and has had pouchitis episodes in the past. SHe sees
Dr. ___, Dr. ___, Drs. ___ (GI), Dr.
___, and
Dr. ___ at ___ (Liver).
She reports right lower abdomen cramping and pressure that has
essentially been present since the end of ___ but has
acutely worsened over the past week. She was seen in clinic on
___ for this and on US found to have a left sided peritoneal
inclusion cyst that was drained by ___ on ___. At that time a
right sided ovarian cyst was also noted, for which she was
referred to ___ clinic (Dr ___ and recommended for
observation. Following seen she was again seen in the ED on ___
for abdominal pain and distenstion and was found to have a right
adnexal cyst (possibly peritoneal inclusion cyst), small pelvic
free fluid and fibroid uterus on CT. This was also confirmed on
ultrasound. ED diagnosis was constipation although no
significant burden was seen on imaging. She did not respond to
disimpaction and enemas and was discharged on bowel regimen. She
has been using oxycodone, ibuprofen for pain. Her LMP was
___. Since discharge from ED on ___, she has had only one
small liquid BM over past 48 hours despite the bowel regimen,
(normally has 5 BMs daily) and also has very poor urine output
with frequent small voids and urinary urgency sxs. She denies
any dysuria, fever, nausea, vomiting, headache. She denies chest
pain, shortness of breath. Endorses non propductive cough and
chills.
She initially presented to ___ UC and was referred here.
In the ED, initial VS were: 98.1 74 ___ 99% RA
ED physical exam was recorded as:
In no acute distress
Abd with mild diffuse discomfort to palpation, voluntary
guarding, no rebound. Mild distension
POCUS with distended bladder, apparent pelvic adnexal cyst with
? loculations
ED labs were notable for:
lipase 73, otherwise all normal
TVUS showed no significant change compared to 3 days prior. An
anechoic right adnexal cyst measures up to 6.1 cm, possibly a
peritoneal inclusion cyst. There is persistent free fluid the
pelvis, portions with homogeneous internal echoes
suggestive of proteinaceous content. The uterus is fibroid.
She was given several doses of IV reglan, Ativan and NS. She
declined a NGT. 400+ straw colored urine drained from straight
cath of bladder.
Surgery was consulted, did not feel there was a role for
surgical intervention.
Admitted to medicine given ongoing abd pain, nausea.
Past Medical History:
PAST MEDICAL HISTORY:
- UC s/p total colectomy and ileal pouch-anal anastomosis (___)
c/b recurrent pouchitis and intraabdmoinal abscess
- PSC
- SBO
- Vit D deficiency
- GERD
- Hx of hip bursitis
- Depression
- Anxiety
- Bipolar disorder (per patient)
- PTSD
- Eating disorder
PSH:
- ___ Total colectomy with ileoanal pouch and diverting
ileostomy (c/b sepsis and abscess)
- ___ Ileostomy takedown and reversal
- Broken ankle surgery
- Sinus surgery
- Wisdom teeth extraction
Social History:
___
Family History:
- Father: Living ___. ___ disease, depression, IBS
- Mother: ___, arthritis
- MGF: HTN
- Uncle: ___ Cancer
Physical Exam:
Admission Exam:
Gen: appears uncomfortable, sleepy but arousable, lying in bed
Eyes: EOMI, sclerae anicteric
ENT: MMM, OP clear
Cardiovasc: RRR, no MRG, full pulses, no edema
Resp: normal effort, no accessory muscle use, lungs CTA ___.
GI: soft, diffusely tender to palpation with no rebound or
guarding, worst in RLQ, ND, bowel sounds present. Multiple well
healed scars seen
MSK: No significant kyphosis. No palpable synovitis.
Skin: No visible rash. No jaundice.
Neuro: AAOx3. No facial droop.
Psych: tearful, anxious
Discharge Exam:
Afebrile, aVSS
Odd affect
Appears overall well, encountered eating, ate entire ___ of
breakfast
Abdomen is soft, NT, ND, prior well healed surgical scars,
ecchymoses from heparin injections
___ exam notable for bilateral ___ strength at major joints, full
sensation bilaterally, normal reflexes. However, she at several
times appeared to be volitionally avoiding lifting her leg as
evidence by lack of contralateral downward force indicating lack
of effort. When distracted she is able to lift leg off bed
without difficulty. Gait is normal when she is not being
observed though with observation she drags her left foot though
has clear normal dorsiflexion
Pertinent Results:
Admission Labs:
___ 07:55PM GLUCOSE-82 UREA N-8 CREAT-0.6 SODIUM-141
POTASSIUM-4.0 CHLORIDE-104 TOTAL CO2-21* ANION GAP-20
___ 07:15PM URINE UCG-NEGATIVE
___ 07:15PM URINE RBC-0 WBC-2 BACTERIA-FEW YEAST-NONE
EPI-8
___ 08:06PM COMMENTS-GREEN TOP
___ 07:55PM LIPASE-73*
___ 07:15PM URINE MUCOUS-RARE
Discharge Labs:
None on day of discharge
Reports:
Pelvic US :
No significant change compared to 3 days prior.
1. An anechoic right adnexal cyst measures up to 6.1 cm and may
representa peritoneal inclusion cyst.
2. There is persistent free fluid the pelvis, portions with
homogeneous
internal echoes suggestive of proteinaceous content. Stable
compared to prior examination
3. The uterus is fibroid.
4. Tubular structure in the left adnexa may represent a
hydrosalpinx versus a small bowel loop although peristalsis was
not observed during the examination
MRI L-Spine:
1. Essentially unremarkable MR of the lumbar spine without
evidence of spinal canal or neural foraminal narrowing.
2. A large right adnexal cyst is better described on prior CT
abdomen and
pelvis of ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Budesonide 9 mg PO DAILY
2. Cholestyramine 4 gm PO DAILY
3. Escitalopram Oxalate 5 mg PO DAILY
4. Famotidine 20 mg PO BID
5. Fludrocortisone Acetate 0.1 mg PO DAILY
6. HydrOXYzine 100 mg PO QHS
7. Multivitamins 1 TAB PO DAILY
8. Ursodiol 600 mg PO BID
9. Vitamin D ___ UNIT PO DAILY
10. Vancomycin Oral Liquid ___ mg PO/NG Q6H
11. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath
12. butalbital-acetaminophen-caff 50-325-40 mg oral Q6H:PRN
headache
13. Diazepam 10 mg PO QHS
14. Fluticasone Propionate 110mcg 2 PUFF IH BID
15. olopatadine 0.1 % ophthalmic BID
16. Probiotic (B.breve-L.acid-L.rham-S.thermo;<br>L.
acidophilus-L. rhamnosus;<br>L.acidophilus-Bif.
animalis;<br>L.rhamn ___
acidophilus;<br>lactobacillus comb no.10;<br>lactobacillus
combination no.4;<br>lactobacillus combo no.11) 15 billion cell
oral DAILY
17. Metadate CD (methylphenidate) 20 mg oral QAM
18. Methylphenidate SR 72 mg PO QAM
19. LORazepam 0.5 mg PO Q6H:PRN nausea
20. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Mild
21. Metoclopramide 5 mg PO Q8H nausea
Discharge Medications:
1. Guaifenesin-Dextromethorphan 5 mL PO Q6H:PRN cough
RX *dextromethorphan-guaifenesin 100 mg-10 mg/5 mL 5 ml by mouth
Q6Hr Refills:*0
2. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath
3. Budesonide 9 mg PO DAILY
4. butalbital-acetaminophen-caff 50-325-40 mg oral Q6H:PRN
headache
5. Cholestyramine 4 gm PO DAILY
6. Diazepam 10 mg PO QHS
7. Escitalopram Oxalate 5 mg PO DAILY
8. Famotidine 20 mg PO BID
9. Fludrocortisone Acetate 0.1 mg PO DAILY
10. Fluticasone Propionate 110mcg 2 PUFF IH BID
11. HydrOXYzine 100 mg PO QHS
12. LORazepam 0.5 mg PO Q6H:PRN nausea
13. Metadate CD (methylphenidate) 20 mg oral QAM
14. Methylphenidate SR 72 mg PO QAM
15. Metoclopramide 5 mg PO Q8H nausea
16. Multivitamins 1 TAB PO DAILY
17. olopatadine 0.1 % ophthalmic BID
18. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Mild
RX *oxycodone 5 mg ___ tablet(s) by mouth Q4HR Disp #*40 Tablet
Refills:*0
19. Probiotic (B.breve-L.acid-L.rham-S.thermo;<br>L.
acidophilus-L. rhamnosus;<br>L.acidophilus-Bif.
animalis;<br>L.rhamn ___
acidophilus;<br>lactobacillus comb no.10;<br>lactobacillus
combination no.4;<br>lactobacillus combo no.11) 15 billion cell
oral DAILY
20. Ursodiol 600 mg PO BID
21. Vancomycin Oral Liquid ___ mg PO Q6H
22. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Flu-like upper respiratory infection
Abdominal pain secondary to right-sided ovarian cyst
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: PELVIS U.S., TRANSVAGINAL
INDICATION: History: ___ with new urinary retention, know 5.6cm R adnexal
mass // eval adnexal mass
TECHNIQUE: Grayscale ultrasound images of the pelvis were obtained with
transabdominal approach followed by transvaginal approach for further
delineation of uterine and ovarian anatomy.
COMPARISON: ___ pelvic ultrasound
FINDINGS:
The uterus is anteverted and measures 8.4 x 4.2 x 4.5 cm. The endometrium is
homogenous and measures 1 mm. Multiple fibroids are again seen. A fibroid
arising from the right aspect of the uterine body measures 1.9 x 1.7 cm. A
fibroid arising from the posterior aspect of the left uterine body measures
2.3 x 1.1 cm.
An anechoic cyst in the right adnexa measuring 6.1 x 4.0 x 4.7 cm is
unchanged. The adjacent ovarian tissue demonstrates normal vascularity. The
left ovary is normal. A 5.4 x 1.4 cm fluid containing structure in the region
of the left adnexa may represent a hydrosalpinx. A moderate amount of free
fluid in the pelvis is overall similar in quantity to the prior examination.
However, portions of the free fluid demonstrate homogeneous internal echoes
related to proteinaceous content.
IMPRESSION:
No significant change compared to 3 days prior.
1. An anechoic right adnexal cyst measures up to 6.1 cm and may represent a
peritoneal inclusion cyst.
2. There is persistent free fluid the pelvis, portions with homogeneous
internal echoes suggestive of proteinaceous content. Stable compared to prior
examination
3. The uterus is fibroid.
4. Tubular structure in the left adnexa may represent a hydrosalpinx versus a
small bowel loop although peristalsis was not observed during the examination
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with cough, pleuritic chest pain // r/o pna
r/o pna
IMPRESSION:
In comparison with the study of ___, there is no interval change
or evidence of acute cardiopulmonary disease. No pneumonia, vascular
congestion, or pleural effusion.
Radiology Report
EXAMINATION: SPLEEN ULTRASOUND
INDICATION: ___ year old woman with pharyngitis, flu-like symptoms, possible
mono // assess for splenomegaly
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: CT abdomen and pelvis dated ___.
FINDINGS:
SPLEEN: Normal echogenicity, measuring 9.5 cm. No focal lesions.
IMPRESSION:
No splenomegaly.
Radiology Report
EXAMINATION: MR ___ SPINE W/O CONTRAST ___ MR SPINE
INDICATION: ___ year old woman with multiple medical issues, now with urinary
retention, left leg/ankle weakness, back pain, ankle clonus (bilateral) //
eval for cauda equina syndrome eval for cauda equina syndrome
TECHNIQUE: Sagittal imaging was performed with T2, T1, and STIR technique,
followed by axial T2 imaging.
COMPARISON: CT abdomen and pelvis performed ___.
FINDINGS:
Alignment of the lumbar spine is anatomic. Bone marrow signal intensity is
within normal limits. Disc signal intensity and heights are preserved. There
is no acute fracture. The conus terminates at the L1 level. Spinal canal is
normal in caliber. There is no abnormal prevertebral soft tissue edema. No
epidural abnormality is identified.
There are no significant degenerative changes. There is no appreciable neural
foraminal narrowing.
Right adnexal cyst is partially imaged (07:23), previously described on CT
abdomen and pelvis dated ___. No appreciable retroperitoneal
abnormality is identified.
IMPRESSION:
1. Essentially unremarkable MR of the lumbar spine without evidence of spinal
canal or neural foraminal narrowing.
2. A large right adnexal cyst is better described on prior CT abdomen and
pelvis of ___.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Abd pain
Diagnosed with Unspecified abdominal pain
temperature: 98.1
heartrate: 74.0
resprate: 16.0
o2sat: 99.0
sbp: 104.0
dbp: 80.0
level of pain: 9
level of acuity: 3.0 | ___ yo female with hx UC s/p colectomy with ileal pouch
anastomosis c/b recurrent pouchitis, on Vedolizumab and
Budesonide, primary sclerosing cholangitis, recurrent peritoneal
inclusion cysts s/p ___ drainage on ___, voiding dysfunction
suspected ___ incomplete bladder emptying with improvement with
Intermittent straight cath and pelvic ___ in ___. admitted
originally with diffuse abdominal pain, decreased UOP and
flu-like symptoms (headache, body aches, cough, sore throat). |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with a PMH significant for ___ and pAFib who had transverse
colectomy in ___ for colon cancer who has had approximately ___
SBOs over the past 3 decades, none of which have required
operative management. He was feeling well in his usual state of
health until around 6pm last night when he experienced band like
epigastric pain. The pain is intermittent and woke him up
several times throughout the night always in the same location.
He reports some nausea with no emesis. He did have a small bowel
movement and passed flatus this morning. He is currently
experiencing epigastric pain.
Past Medical History:
pAFib (on Coumadin), HTN, Cancer s/p transverse colectomy
and chemotherapy (___), Hyperplastic colonic polyps, and
adenomatous polyps (Last c-scope ___, melanoma, bilateral lung
cancer (RLL SCC, LLL Adenoca), Cardiac stress and perfusion
normal ___, h/o diastolic CHF, Ocular myasthenia ___,
Hypertension, Hyperlipidemia, Peripheral neuropathy, Lumbar
radiculopathy, Gout
Social History:
___
Family History:
Dad with CHF, mom with DM and celiac sprue (only autoimmune dz
in the family).
Physical Exam:
Upon admission:
Pain ___ 122/45 17 92% RA
Gen: Uncomfortable but NAD, A&O, Pleasant and conversive,
cooperative with exam
CV: RRR, No R/G/M
RESP: CTAB
ABD: Soft, moderately distended with epigastric tenderness, no
guarding, no rebound. NGT placed in ED with 2000cc of brown/tan
drainage
EXT: WWP BLE, no appreciable edema
Upon discharge:
VITALS: 98.8 90 109/53 18 97RA
GEN: AAOx3, NAD
HEART: RRR S1S2
LUNGS: CTAB no respiratory distress
AB: soft, NT, mild distention
EXT: warm well perfused
Pertinent Results:
___ 06:20AM BLOOD WBC-7.1 RBC-3.81* Hgb-11.6* Hct-36.0*
MCV-94 MCH-30.4 MCHC-32.2 RDW-15.2 Plt ___
___ 07:15AM BLOOD ___
___ 06:20AM BLOOD Glucose-114* UreaN-16 Creat-1.1 Na-147*
K-4.3 Cl-109* HCO3-31 AnGap-11
CT abdomen/pelvis ___
Complete small bowel obstruction with a transition in the right
lower quadrant most consistent with adhesion. No pneumatosis,
free air or free fluid.
Medications on Admission:
Torsemide 20 mg
Doxazosin 2 mg daily
Pravastatin 40 mg daily
Amlodipine 10 mg daily
Lisinopril 20 mg daily
Coumadin 5 mg
Allopurinol ___ mg
Metoprolol Succinate 50mg daily
Discharge Medications:
1. Torsemide 20 mg PO DAILY
2. Allopurinol ___ mg PO DAILY
3. Amlodipine 10 mg PO DAILY
4. Doxazosin 1 mg PO BID
5. Lisinopril 20 mg PO DAILY
6. Metoprolol Succinate XL 50 mg PO DAILY
7. Pravastatin 40 mg PO DAILY
8. Warfarin 5 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Small bowel obstruction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Colectomy for colon cancer with prior small bowel obstruction now
with lower abdominal pain. Evaluate for a small bowel obstruction.
TECHNIQUE: MDCT axial images were acquired through the abdomen and pelvis
without the administration of IV contrast. Oral contrast was administered.
Coronal and sagittal reformations were provided and reviewed.
DLP: 1000.93 mGy/cm.
COMPARISON: CT abdomen pelvis ___.
FINDINGS: The included lung bases show no pleural effusion or pneumothorax.
The imaged heart is normal in size. There is a trace, physiologic pericardial
effusion.
The oral contrast bolus remains within the stomach. Contrast is also seen in
the esophagus, consistent with reflux. Loops of small bowel are dilated and
range up to 4.2 cm. There is a transition of bowel caliber seen within the
right lower quadrant, after which the distal loops of small and large bowel
are collapsed. Fecalization of small bowel contents is noted at this level as
well. There is no bowel wall thickening. There is no free air or free fluid.
There is no pneumatosis. The right and transverse colon is surgically absent.
Evaluation of the intra-abdominal organs is limited by lack of intravenous
contrast. Within this limitation, the liver, gallbladder, spleen, pancreas
and adrenal glands are unremarkable. The kidneys show no nephrolithiasis or
hydronephrosis. A simple 2.3 mm cyst in the upper pole of the right kidney is
noted.
There is a moderate amount of atherosclerosis within a non aneurysmal aorta.
Dense calcifications are noted at the origin of the celiac and superior
mesenteric arteries. Evaluation for vessel patency is limited by lack of IV
contrast.
Pelvis: The right lateral wall of the bladder is seen within a right inguinal
hernia. The prostate and seminal vesicles are unremarkable. There is mild
sigmoid diverticulosis without diverticulitis.
Bones: Spinal hardware is seen within the spinous process of L3. There are
mild degenerative changes of the lumbar spine with loss of disc space, worse
at L3-4. There are no concerning lytic or blastic lesions. A sclerotic focus
within the right iliac wing is unchanged from ___ (2:53).
IMPRESSION: Complete small bowel obstruction with a transition in the right
lower quadrant most consistent with adhesion. No pneumatosis, free air or
free fluid.
Radiology Report
PORTABLE CHEST ___
COMPARISON: ___ and ___ radiographs.
FINDINGS: Interval placement of nasogastric tube, with tip terminating in the
stomach. Stable cardiomegaly and persistent right pleural effusion opacity,
which appears to predominantly be due to pleural thickening on recent
abdominal CT of ___ with only a trace amount of pleural fluid.
There is also either pleural thickening or fluid within the adjacent fissure.
Mild volume loss is present in the right hemithorax and note is made of volume
loss and scarring in the right lower lobe and right middle lobe. The left
lung demonstrates surgical chain sutures in the mid lung region and is
otherwise clear.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Abd pain
Diagnosed with INTESTINAL OBSTRUCT NOS, HYPERTENSION NOS, HYPERCHOLESTEROLEMIA, LONG TERM USE ANTIGOAGULANT
temperature: 97.8
heartrate: 93.0
resprate: 16.0
o2sat: 100.0
sbp: 147.0
dbp: 55.0
level of pain: 13
level of acuity: 3.0 | The patient is an ___ year old male who was admitted to the Acute
Care Surgery service with a small bowel obstruction. He
presented to the ED with abdominal pain, and subsequent CT scan
showed a complete small bowel obstruction with a transition in
the right lower quadrant. An NG tube was inserted in the ED,
and the patient was transferred to the floor for further care.
All of the patient's home medications, including coumadin, were
held while the NG tube was in place. The patient received
morphine for pain, only after being examined by a physician. On
HD2, the patient removed his NG tube in the shower. The NG tube
was replaced that day, and subsequent CXR confirmed placement.
The patient reported flatus on HD3, and after a clamp trial
overnight, the NG tube was removed on HD4 in the morning. At
that time, his diet was advanced to clears, and later to a
regular, which he tolerated well. His home medications,
including coumadin, were restarted on HD4. At the time of
discharge on HD5, his INR was 1.5, and he was advised to follow
up with his PCP. He was in stable condition, ambulating and
voiding independently. |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
lisinopril
Attending: ___.
Chief Complaint:
Dysuria
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w/ DM, HTN, h/o SBO, h/o ovarian cancer, p/w dysuria and
___.
Pt reports dysuria x 2 weeks. She was treated with Bactrim x 3
days. However, she cont. to have dysuria and increased urgency.
Wears diapers at baseline. also endorses decreased appetite over
the last few days. Denies fever, chills, back pain, n/v. She
reports chronic intermittent diarrhea - at baseline.
This am, pt also feel to the floor from bed while trying to
walk to dresser. Pt reports hitting her R arm. Denies LOC. The
fall was unwitnessed. Daughter found pt on the ground about 45
minutes later.
PCP ___ ___ showed K 5.5, BUN 44, Cr 1.6 increase from
___, and referred pt to the ED. Family denies recent new
meds other than Bactrim. no OTC NSAIDS use. denies sig.
dizziness/lightheadedness while at all. Pt does report that it
has been hard to urinate.
In the ED, initial vitals were: 98.3 82 160/80 20 95% RA
- Labs were significant for K 6.0, Cr 1.3, no leukocytosis, UA
w/ pos nitrite and large leuks; CK 43
- The patient was given
___ 15:44 IVF 1000 mL NS 1000 mL
___ 16:50 IV CeftriaXONE 1 gm
___ 19:36 PO Acetaminophen 1000 mg
___ 19:36 PO Phenazopyridine 100 mg
Repeat K was 5.2.
Past Medical History:
History of Ovarian Cancer
- s/p TAH/BSO ___ years ago
Hypertension
Depression
recent SBO in ___
DM
occasional pipe smoker
Social History:
___
Family History:
Diabetes and HTN run in the family.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 97.7 105/68 75 18 97RA
General: Alert, oriented to person and hospital
HEENT: Sclera anicteric, dry MM
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
BACK: no CVA tenderness
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: moving all extremities
DISCHARGE PHYSICAL EXAM:
VS - 98.5 110/68 65 16 95% on RA
General: NAD, comfortable
HEENT: Sclera anicteric, EOMI, swelling of left>right lower
eyelid mildly improved, MMM, patent oropharynx, no teeth
Neck: Supple, no LAD
CV: RRR, normal S1/S2, no murmurs/rubs/gallops
Lungs: CTAB, no increased work of breathing, no
wheezes/rales/rhonchi
Abdomen: Non-tender. LLQ hernia is firm and distended. Otherwise
soft and non-distended. +BS. No HSM. No rebound or guarding.
GU: Wearing a diaper.
Ext: Warm and well perfused. No clubbing, cyanosis, or edema.
Neuro: Moving all extremities equally.
Skin: No rashes or bruises.
Pertinent Results:
ADMISSION LABS
===============
___ 12:02PM BLOOD WBC-8.3 RBC-4.39 Hgb-11.2 Hct-38.2 MCV-87
MCH-25.5* MCHC-29.3* RDW-15.6* RDWSD-49.1* Plt ___
___ 12:02PM BLOOD Neuts-57.3 ___ Monos-7.2 Eos-3.1
Baso-1.0 Im ___ AbsNeut-4.78 AbsLymp-2.57 AbsMono-0.60
AbsEos-0.26 AbsBaso-0.08
___ 12:02PM BLOOD UreaN-44* Creat-1.6* Na-138 K-5.5* Cl-105
HCO3-24 AnGap-15
___ 12:02PM BLOOD TSH-0.53
___ 12:02PM BLOOD CRP-39.8*
___ 09:00PM BLOOD K-5.2*
PERTINENT FINDINGS
===================
Renal Ultrasound ___:
1. Normal renal ultrasound.
2. Splenic cyst with layering debris.
Head CT ___:
No acute intracranial process.
DISCHARGE LABS:
================
___ 07:15AM BLOOD WBC-6.6 RBC-3.84* Hgb-9.9* Hct-32.5*
MCV-85 MCH-25.8* MCHC-30.5* RDW-15.1 RDWSD-45.3 Plt ___
___ 07:15AM BLOOD Plt ___
___ 07:15AM BLOOD Glucose-147* UreaN-31* Creat-1.0 Na-139
K-4.8 Cl-108 HCO3-24 AnGap-12
___ 07:15AM BLOOD Calcium-8.6 Phos-3.7 Mg-2.0
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO Q8H:PRN pain
2. Atenolol 25 mg PO DAILY
3. Docusate Sodium 100 mg PO BID:PRN constipation
4. Hydrochlorothiazide 12.5 mg PO DAILY
5. Losartan Potassium 100 mg PO DAILY
6. Aspirin 81 mg PO DAILY
7. Mirtazapine 15 mg PO QHS
8. MetFORMIN (Glucophage) 850 mg PO BID
9. calcium carbonate-vitamin D3 500 mg(1,250mg) -200 unit oral
BID
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN pain
2. Aspirin 81 mg PO DAILY
3. Mirtazapine 15 mg PO QHS
4. Atenolol 25 mg PO DAILY
5. calcium carbonate-vitamin D3 500 mg(1,250mg) -200 unit oral
BID
6. Docusate Sodium 100 mg PO BID:PRN constipation
7. Hydrochlorothiazide 12.5 mg PO DAILY
8. Losartan Potassium 100 mg PO DAILY
9. MetFORMIN (Glucophage) 850 mg PO BID
10. Cefpodoxime Proxetil 100 mg PO Q12H
RX *cefpodoxime 100 mg 1 tablet(s) by mouth Every 12 hours Disp
#*8 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
- UTI
- ___
Secondary:
- Diabetes
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ year old woman with diabetes and unwitnessed fall and possible
head strike. Evaluate for acute intracranial abnormality such as bleed.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal reformations as well as bone algorithm
reconstructions were provided and reviewed.
DOSE: Total DLP (Head) = 803 mGy-cm.
COMPARISON: CT head from ___ and MR head from ___.
FINDINGS:
There is no evidence of acute infarction, hemorrhage, or edema.. A calcified
lesion in the left cerebellar peduncle is stable and likely reflects a
cavernoma, as previously noted on prior MRI. There is prominence of the
ventricles and sulci suggestive of involutional changes. Periventricular and
deep white matter hypodensities likely reflect chronic microangiopathic
changes. There is no evidence of fracture. The visualized portion of the
paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The
visualized portion of the orbits are unremarkable.
IMPRESSION:
No acute intracranial process.
Radiology Report
EXAMINATION: RENAL U.S.
INDICATION: Evaluate for hydronephrosis or other evidence of renal
obstruction, in a patient with ___ and difficulty urinating.
TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were
obtained.
COMPARISON: CT abdomen/pelvis from ___.
FINDINGS:
The right kidney measures 11.4 cm. The left kidney measures 10.7 cm. There is
no hydronephrosis, stone, or solid mass bilaterally. Normal cortical
echogenicity and corticomedullary differentiation are seen bilaterally. As on
prior CT, there are bilateral simple renal cysts, measuring 8 x 9 x 10 mm in
the upper pole of the left kidney, 15 x 14 mm in the upper pole of the right
kidney, and 12 x 15 mm in the lower pole of the right kidney. A complex cyst
in the lower pole of the spleen measuring 4.8 x 4.8 x 5.3 cm is similar in
size compared to ___, and demonstrates some layering debris.
The bladder is completely decompressed and cannot be fully assessed on the
current study.
IMPRESSION:
1. Normal renal ultrasound.
2. Splenic cyst with layering debris.
Gender: F
Race: BLACK/CAPE VERDEAN
Arrive by AMBULANCE
Chief complaint: Dysuria
Diagnosed with Urinary tract infection, site not specified, Acute kidney failure, unspecified
temperature: 98.3
heartrate: 82.0
resprate: 20.0
o2sat: 95.0
sbp: 160.0
dbp: 80.0
level of pain: UTA
level of acuity: 3.0 | Ms. ___ is a ___ year old woman with a history of T2DM, HTN,
SBO, and ovarian cancer presenting with dysuria and ___.
# UTI: Patient presented with dysuria/burning and urinary
frequency s/p 3 days of Bactrim treatment. UA was frankly
positive for UTI, urine cultures were sent and Pyridium as well
as CTX was started. Given positive nitrite in UA, suspect GNRs
most likely E. coli. No systemic signs of infection including no
fever or altered mental status. Renal ultrasound was performed
as patient complained that with urinary frequency she had the
sensation of not completely excreting all of her urine. Renal
ultrasound was normal. Patients symptoms improved quickly. Urine
cultures grew mixed flora, consistent with fecal contamination.
Pyridium was given for 3 days until symptom resolution. Given
history of failed treatment, and diabetes, was deemed complex
UTI and discharged on Cefpodoxime for 7 days total (Last day
___.
# ___: Seen at ___ office, found to have SCr 1.6 (baseline 0.9).
Thought to be pre-renal in setting of decreased po intake and
diarrhea. Post renal etiology ruled out with normal renal
ultrasound, without evidence of hydronephrosis or other renal
pathology. Patient was given 1L NS, and PO intake was
encouraged. SCr normalized to 1.0 at time of discharge. Home
hydrochlorothiazide and losartan held until normalization.
# Hyperkalemia: Elevated to 6.0 on admission. No EKG changes
detected. Held losartan and gave IVF. Down trended without
intervention. Potassium 4.8 at discharge.
# Swollen eyes: Noted to have inferior ___ swelling
R>L. Her ___ swelling was be due to an allergic
reaction, and was treated with Ceterizine with good effect.
# Fall: Slow, low impact fall at home. No acute intracranial
process on head CT, no loss of consciousness, and no apparent
altered mental status on exam or per daughter Most likely due to
a mechanical issue as she walks with a cane and there is no
evidence of hypotension (no dizziness/lightheadedness) and
orthostatics were normal. Patient was evaluated by ___ who
recommended home ___.
# Nutrition: Poor appetite recently. Seen by nutrition who
recommended glucerna supplementation TID for calorie
requirements.
# Diarrhea: Chronic, intermittent for ___ years since
hysterectomy. Intermittent constipation resolved on arrival to
floor.
# DM: Well controlled on metformin. Insulin sliding scale in the
hospital and diabetes diet.
# HTN: Well controlled. Initially held hydrochlorothiazide,
losartan while ___ and atenolol until confirmed no episodes of
hypotension given recent falls.
# Depression: Stable. Continued home Mirtazapine. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Estrogens / Ancef / Tegretol / Keflex / Allegra /
Tequin / Minocin / Forteo / carbamazepine / Cephalosporins
Attending: ___.
Chief Complaint:
Confusion/dysarthria
Major Surgical or Invasive Procedure:
Lumbar puncture
History of Present Illness:
___ year old woman with history of SLE, c/b Devic's neuromyelitis
optica and transverse myelitis on chronic prednisone presenting
with episode of altered mental status. Staff at her facility
reported that she became confused around 10 AM with speech
change, facial clonus, auditory hallucinations and SpO2 82%.
She was recently admitted with hallucinations s/p left hip
repair, thought to be due to post-op delirium and steroid
psychosis which resolved. During that admission she developed
episodes of acute slurred speech and feeling unwell. Symptoms
would often start with a feeling of chest heaviness and dyspnea.
She had a head CT which did not show any acute intracranial
process. She also had an EEG which captured these episodes and
showed non specific slowing but no epileptiform activity.
Neurology did not recommend any anti-epileptic medication at
that time.
On arrival to ER, vitals 101.6 121 ___ 94% RA. Patient
feeling generally unwell but no focal symptoms. Chest x-ray
without infiltrate. Her tachycardia improved with IV fluid and
antipyretics. While in the ED patient had an 'episode' similar
to previous admission during which she has a staring spell with
tachypnea. This resolved sponataneously. She was given
vancomycin due to concern for health care associated infection.
She was also given baclofen, due to report that baclofen pump
was due to be refilled. Of note, it was interogated on previous
admission and was functioning properly and not due for refill
until ___. Vitals prior to transfer 98.2 102 141/71 25 97% RA.
On the floor, VS are 98.1, 130/74, 82, 118, 98%RA. She feels
well and reports that she has no recollection of any events
since leaving the hospital last night. Currently she is without
hallucinations, feels like she is coming out of a fog but is not
confused about the current situation. She denies any new
weakness, chest pain, SOB, nausea, abdominal pain, hip pain.
Past Medical History:
1) SLE. Complicated by neuromyelitis optica (right eye
blindness)
and pericarditis. Followed by Dr. ___. Had been treated with
cytoxan. On Pred.
2) Transverse Myelitis diagnosed in ___ after patient presented
with fall. Complicated by neurogenic bladder requiring ileal
loop diversion ___. On steroids. Had baclofen pump placed in
___.
3) h/o urosepsis complicated by acral necrosis while on pressors
4) h/o frequent nephrolithiasis with staghorn calculi s/p
lithotripsy, urostomy tube placement
5) Right lower extremity DVT ___, treated with coumadin
6) Steroid-induced hyperglycemia
7) Bilateral knee arthritis
8) Left eye capsular ossification or a secondary cataract,
corrected w/ laser surgery ___
9) Hypothyroidism
10) Osteoporosis secondary to chronic steroids
11) Liver hemangioma
12) HTN
Social History:
___
Family History:
as per prior OMR notes
Mother died at ___ metastatic BCA
Father died at ___ aplastic anemia
only child
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals-98.1, 130/74, 82, 118, 98%RA
General: Sitting up in bed comfortably. Alert, interactive,
oriented x3. Smiling and pleasant, NAD. Not attending to
external stimuli. HEENT: sclera anicteric, conjunctiva clear. L
exotropia. Dry mucous membranes, tongue tremor.
Neck: Supple, no LAD
CV- regular rhythm, no murmurs
Pulm- CTAB, no wheezes or rales
Abd- soft, NT, urostomy conduit draining dark urine with
sediment
Ext- left lateral leg with 3 surgical incisions, staples in
place, C/D/I and non-tender. No edema. WWP pulses symmetric
Neuro- R eye blindness (chronic), otherwise CN2-12 intact. ___ ___
plegia, able to wiggle toes L>R. ___ strength ___ UE
DISCHARGE PHYSICAL EXAM:
VS 98.6, 124/62, 87, 100, 98% on RA
General: Sitting up in bed comfortably. Alert, interactive,
oriented x3. Smiling and pleasant, NAD. Not attending to
external stimuli. HEENT: sclera anicteric, conjunctiva clear. L
exotropia. Dry mucous membranes, tongue tremor.
Neck: Supple, no LAD
CV- regular rhythm, no murmurs
Pulm- CTAB, no wheezes or rales
Abd- soft, NT, urostomy conduit draining clear fluid with some
whitish sediment
Ext- left lateral leg with 3 surgical incisions, staples
removed, C/D/I and non-tender. No edema. WWP pulses symmetric
Neuro- R eye blindness (chronic), otherwise CN2-12 intact. ___ ___
plegia, able to wiggle toes L>R. ___ strength ___ UE
Pertinent Results:
Admission Labs:
___ 10:00AM SODIUM-135 POTASSIUM-4.4 CHLORIDE-105
___ 06:00AM UREA N-20 CREAT-0.5 SODIUM-136 POTASSIUM-4.5
CHLORIDE-107 TOTAL CO2-18* ANION GAP-16
___ 06:00AM CALCIUM-8.4 PHOSPHATE-2.5* MAGNESIUM-2.2
___ 06:00AM WBC-13.2* RBC-3.40* HGB-10.8* HCT-33.8*
MCV-99* MCH-31.7 MCHC-31.9 RDW-13.9
___ 06:00AM PLT SMR-NORMAL PLT COUNT-421
___ 06:00AM LD(LDH)-418* ALK PHOS-159*
___ 03:00PM URINE BLOOD-SM NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-LG
___ 03:00PM URINE RBC-25* WBC-158* BACTERIA-FEW YEAST-NONE
EPI-0
Discharge Labs:
___ 07:36AM BLOOD WBC-9.5 RBC-3.45* Hgb-10.9* Hct-34.2*
MCV-99* MCH-31.7 MCHC-32.1 RDW-13.5 Plt ___
___ 07:36AM BLOOD Glucose-101* UreaN-28* Creat-0.6 Na-141
K-4.5 Cl-108 HCO3-25 AnGap-13
___ 07:36AM BLOOD Calcium-9.3 Phos-2.6* Mg-2.3
Imaging/Reports:
#CXR ___
IMPRESSION:
No acute cardiopulmonary process. No significant interval
change.
#Renal U/S ___
IMPRESSION:
1. Distended calices in the upper pole of the left kidney with
multiple shadowing stones throughout the left kidney, similar to
prior CT. No evidence of left hydronephrosis.
2. Right kidney not well visualized, but no evidence of right
hydronephrosis.
# KUB ___
FINDINGS:
A nonspecific bowel gas pattern is seen without evidence of
obstruction.
Marked levoscoliosis is again noted, relatively similar to ___. Radiopaque densities overlying the left renal
pelvis likely corresponds to previously noted calculi. A
baclofen pump is seen overlying the left lower quadrant with
intact wires running posteriorly into the midline spine. Exact
location of the wires cannot be identified on these single
projection images but appear similar to CT from ___.
Left femoral surgical hardware is partially visualized.
IMPRESSION:
Baclofen pump with intact wires running posteriorly appear in
similar position to CT from ___.
#EEG ___
IMPRESSION: This was a normal continuous video EEG. There were
no
epileptiform discharges or electrographic seizures.
HEAD MRI ___
IMPRESSION:
1. No acute infarct, intracranial hemorrhage or space-occupying
lesion.
2. Diffuse white matter signal abnormalities most likely
represent the sequela of small vessel ischemic disease.
Microbiology:
___ Urine culture
URINE CULTURE (Final ___:
YEAST. 10,000-100,000 ORGANISMS/ML..
___ Blood culture
Blood Culture, Routine (Final ___: NO GROWTH.
___ 8:38 am CSF;SPINAL FLUID TUBE 3. LP.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method, please
refer to hematology for a quantitative white blood cell count..
FLUID CULTURE (Final ___: NO GROWTH.
VIRAL CULTURE (Preliminary): NO VIRUS ISOLATED.
___ 8:34 am URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___:
YEAST. 10,000-100,000 ORGANISMS/ML..
___ 11:03 am STOOL CONSISTENCY: SOFT Source:
Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Reported to and read back by ___ ___ 3:17PM.
CLOSTRIDIUM DIFFICILE.
Positive for toxigenic C. difficile by the Illumigene
DNA
amplification. (Reference Range-Negative).
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q8H
2. Baclofen 10 mg PO TID
3. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
4. Docusate Sodium 100 mg PO BID
5. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP LEFT EYE BID
6. Enoxaparin Sodium 40 mg SC QPM
7. Levothyroxine Sodium 100 mcg PO DAILY
8. Omeprazole 20 mg PO DAILY
9. PredniSONE 10 mg PO EVERY OTHER DAY
10. PredniSONE 30 mg PO EVERY OTHER DAY
11. Ranitidine 150 mg PO DAILY
12. Senna 8.6 mg PO BID
13. Valsartan 40 mg PO DAILY
14. Ibuprofen 400 mg PO Q8H:PRN pain
15. ertapenem 1 gram injection daily
16. Sodium Bicarbonate 650 mg PO TID
17. Vitamin D 1000 UNIT PO DAILY
18. Heparin Flush (10 units/ml) 2 mL IV DAILY and PRN, line
flush
19. QUEtiapine Fumarate 12.5 mg PO QHS
Discharge Medications:
1. Baclofen 10 mg PO TID
2. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
3. Docusate Sodium 100 mg PO BID
4. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP LEFT EYE BID
5. Heparin Flush (10 units/ml) 2 mL IV DAILY and PRN, line flush
6. Ibuprofen 400 mg PO Q8H:PRN pain
7. Levothyroxine Sodium 100 mcg PO DAILY
8. Omeprazole 20 mg PO DAILY
9. PredniSONE 30 mg PO EVERY OTHER DAY
10. QUEtiapine Fumarate 12.5 mg PO QHS
11. Senna 8.6 mg PO BID
12. Sodium Bicarbonate 650 mg PO TID
13. Valsartan 40 mg PO DAILY
14. Vitamin D 1000 UNIT PO DAILY
15. PredniSONE 10 mg PO EVERY OTHER DAY
16. Fluconazole 200 mg PO Q24H
17. Acetaminophen 650 mg PO Q8H
18. Ranitidine 150 mg PO DAILY
19. MetRONIDAZOLE (FLagyl) 500 mg PO TID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
Altered mental status
Secondary:
Devic's neuromyelitis optica and transverse myelitis
Steroid induced hyperglycemia
hypothyroidism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
HISTORY: Fever, altered mental status.
TECHNIQUE: AP upright and lateral views of the chest.
COMPARISON: ___.
FINDINGS:
The patient is somewhat rotated and thoracolumbar scoliosis is again seen.
Left-sided PICC / midline is again seen, terminating in the region of the
proximal left axillary vein. There is persistent elevation the right
hemidiaphragm with overlying right basilar atelectasis. No focal
consolidation is seen. There is no pleural effusion pneumothorax. Cardiac
mediastinal silhouettes are stable. No pulmonary edema is seen.
IMPRESSION:
No acute cardiopulmonary process. No significant interval change.
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST
INDICATION: ___ year old woman with Devic's NMO/transverse myelitis, SLE, here
with confusion/dysarthria/hallucinations.
TECHNIQUE: Multiplanar, multi sequence MR images of the head were obtained
before and after the administration of intravenous contrast.
COMPARISON: CT head dated ___ and ___.
FINDINGS:
There is no acute infarct or acute intracranial hemorrhage. No mass, mass
effect or midline shift is present. There is no abnormal enhancement. Patchy
and confluent areas of T2 and FLAIR hyperintensity are present within the
periventricular, deep and subcortical white matter, and there are a couple of
foci of hyperintensity within the pons is well. Mild cerebral atrophy is
present with dilatation of the ventricles and widening of the cortical sulci.
Fluid signal is seen within the right mastoid.
IMPRESSION:
1. No acute infarct, intracranial hemorrhage or space-occupying lesion.
2. Diffuse white matter signal abnormalities most likely represent the sequela
of small vessel ischemic disease.
Radiology Report
HISTORY: Ileal diversion, history of staghorn calculus status post
lithotripsy, UTI.
COMPARISON: Comparison made with CT abdomen and pelvis from ___
and renal ultrasound from ___.
TECHNIQUE: Grayscale and color Doppler ultrasound images of the kidneys were
obtained.
FINDINGS:
The right kidney is not well visualized, but measures approximately 10.4 cm
and does not demonstrate evidence of hydronephrosis.
The left kidney measures 12.2 cm. There are distended calices in its upper
pole of the left kidney, similar to prior CT. Multiple shadowing stones are
seen throughout the left kidney. There is no evidence of hydronephrosis.
The bladder is not well visualized on this exam.
IMPRESSION:
1. Distended calices in the upper pole of the left kidney with multiple
shadowing stones throughout the left kidney, similar to prior CT. No evidence
of left hydronephrosis.
2. Right kidney not well visualized, but no evidence of right hydronephrosis.
Radiology Report
EXAMINATION: PORTABLE ABDOMEN
INDICATION: ___ year old woman with SLE complicated by Devic's disease, on
baclofen pump for transverse myelitis, needs pump position assessed prior to
brain MRI. // assess position of baclofen pump
TECHNIQUE: Supine frontal abdominal radiographs were obtained.
COMPARISON: Ultrasound from ___, radiograph from ___
and CT from ___.
FINDINGS:
A nonspecific bowel gas pattern is seen without evidence of obstruction.
Marked levoscoliosis is again noted, relatively similar to ___.
Radiopaque densities overlying the left renal pelvis likely corresponds to
previously noted calculi. A baclofen pump is seen overlying the left lower
quadrant with intact wires running posteriorly into the midline spine. Exact
location of the wires cannot be identified on these single projection images
but appear similar to CT from ___. Left femoral surgical hardware
is partially visualized.
IMPRESSION:
Baclofen pump with intact wires running posteriorly appear in similar position
to CT from ___.
Radiology Report
EXAMINATION: Lumbar puncture under fluoroscopic guidance.
INDICATION: ___ year old woman with SLE complicated by Devic's disease and
transverse myelitis for which she has a baclofen pump, admitted for
hallucinations/confusion concerning possible lupus cerebritis. // LP for
cytology, oligoclonal bands, hSV, VZV PCR (will order)
TECHNIQUE: Fluoroscopic guided lumbar puncture.
COMPARISON: None.
FINDINGS:
The benefits, risks and alternatives of the procedure were explained to the
patient. All questions were answered. Informed consent was obtained and placed
in the chart.
The patient was transported to the special procedure fluoroscopy room and
placed in prone position. A preprocedural time out was performed. The lower
back was prepped and draped in the standard sterile fashion. Lidocaine was
administered at the L4-L5 level for local anesthesia. Under fluoroscopic
guidance, a 22-gauge spinal needle was inserted at the L4-L5 level. A
fluoroscopic image of the lumbar spine was obtained (and retained in the PACS
system), confirming the needle position at L4-L5.
A total of 16.5 cc of clear cerebrospinal fluid was obtained and placed in 4
separate tubes. The needle was subsequently removed.
Patient tolerated the procedure well without immediate complication. The fluid
was brought to the laboratory.
IMPRESSION:
Successful fluoroscopic guided lumbar puncture.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Altered mental status
Diagnosed with FEVER, UNSPECIFIED, SEMICOMA/STUPOR
temperature: nan
heartrate: 131.0
resprate: 30.0
o2sat: 98.0
sbp: 154.0
dbp: 116.0
level of pain: 13
level of acuity: 1.0 | ___ year old woman with history of SLE, Devic's neuromyelitis
optica and transverse myelitis on chronic prednisone, recent
admission for confusion/hallucinations thought to be
post-opering delirium and steroid psychosis, presenting for
recurrence of AMS and dysarthria.
ACTIVE ISSUES
-------------
# Altered mental status: During recent hospitalization, patient
had developed acute episodes of confusion and dysarthria that
was evaluated by a head CT that was negative, and an EEG which
captured one of these episodes and did not show epileptiform
activity. Quetiapine was discontinued for potential
contribution to mental status. Baclofen pump appeared to
working well. TSH was recently normal. Due to non-specific
findings on recent EEG, and report of "clonus-like" activity per
SNF report, a >24hr continuous video EEG was performed showing
no evidence of seizure activity. An MRI head showed no acute
inflammation. LP was performed and CSF studies were benign. It
was unclear what the cause of her ongoing auditory
hallucinations and altered mental status was but infectious
work-up did show yeast growing in her urine cultures. She was
subsequently discharged to complete a 2 week course of
fluconazole. She also developed C.difficile diarrhea during her
hospitalization for which she was also discharged to complete a
2 week course of metronidazole. She was restarted on her home
quetiapine at discharge per Neurology, and will have close
follow-up with her outpatient neurologist.
# Urinary tract infection: Continued on treatment for recent E.
coli and citrobacter UTI with meropenem, course completed on
___. A renal ultrasound did not show evidence of
pyelonephritis. She has a ileal diverting conduit, history of
staghorn calculi, and history of severe urosepsis resulting in
acral necrosis from pressors. The patient did experience an
episode of hypotension without symptoms. Given positive urine
cultures for yeast, she was started on fluconazole on ___
she will complete a 2 week course given her complicated anatomy.
# C. difficile diarrhea: The patient developed diarrhea shortly
after completing her meropenem course. She was found to have
mild C. difficile and was started on metronidazole 500 mg PO q8h
on ___. She should complete a 2 week course (last day
___.
# Left hip fracture s/p ORIF on ___: Surgical sites clean and
without evidence of infection or dehiscence. Pain was well
controlled. Patient was continued on her home tramadol. She was
previously on Lovenox 40 mg; per Orthopedics' instructions, she
completed a 2 week course on ___.
INACTIVE ISSUES
---------------
# ___'s disease: Lupus c/b ___'s neuromyelitis optica and
transverse myelitis, managed by Dr ___, on chronic steroids.
She was continued on her home steroids.
# Steroid induced hyperglycemia: Her hyperglycemia was managed
on an insulin sliding scale.
# Hypothyroidism: continued home levothyroxine |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Nausea, vomiting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ yof with poorly controlled DM, HTN, depression
and history of alcoholism who presents with nausea, vomiting,
and abdominal pain after recent flu-like illness. EMS found
patient to have blood glucose of 525 with temperature of 100.1.
Patient has history of multiple admissions for poor glucose
control including DKA in ___. Patient reports
intermittent compliance with her NPH and checks blood glucose
only in mornings. She initially had several days of myalgias,
rhinorrhea, and general malaise that preceded her nausea,
vomiting, and abdominal pain. Sick contacts of mother and sister
w/ "flu". She denied diarrhea or dysuria. Patient was noted to
have cough in ED.
In the ED: She was found to have K 7.6, bicarb of 8, blood
glucose of 587 and anion gap of 30. She received 3 L of NS, then
switched to MIVF of D5 with K. She was started on on insulin
drip: bolus of 10, then 8 u/hr since 0100. At time of transfer
to the ICU, her blood glucose was 300.
On arrival to CCU: Patient reports abdominal pain is much
improved.
REVIEW OF SYSTEMS: No diarrhea, dysuria
Past Medical History:
DM2 w/moderately severe B nonproliferative diabetic retinopathy
HTN
Depression- one psych hospitalization in ___ for SI
h/o EtOH abuse- never experienced withdrawal sx, in early
remission
Social History:
___
Family History:
Mother with DM2, HTN. No known family history of cancer.
Physical Exam:
ADMISSION
Vitals: T 101 HR 115 BP 121/58 RR 16 O2 100%
Gen: NAD
HEENT: poor dentition
Neck: no JVD
CV: NR, RR, no murmurs
Pulm: CTAB
Abd: NT, ND, soft
Ext: no peripheral edema
Neuro: A&O, no gross deficits
Psych: appropriate
Skin: no lesions noted
DISCHARGE
Vitals: T: 98.1, BP: 120/82, P: 108, R: 18, O2: 100% RA
General: Alert, oriented, no acute distress, obese
HEENT: Sclera anicteric, MMM, oropharynx clear but poor
dentition
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: no rashes
Neuro: CN ___ intact, ___ strength in b/l upper and lower
extremities
Pertinent Results:
ADMISSION
___ 01:00AM GLUCOSE-587* UREA N-30* CREAT-1.4* SODIUM-136
POTASSIUM-7.6* CHLORIDE-99 TOTAL CO2-8* ANION GAP-37*
___ 01:00AM ALT(SGPT)-17 AST(SGOT)-43* ALK PHOS-100 TOT
BILI-0.4
___ 01:00AM LIPASE-22
___ 01:00AM ALBUMIN-4.7
___ 01:00AM K+-6.9*
___ 01:00AM WBC-7.2# RBC-3.66* HGB-10.1* HCT-35.3* MCV-96
MCH-27.5 MCHC-30.6* RDW-16.1*
___ 01:00AM NEUTS-76* BANDS-1 LYMPHS-17* MONOS-6 EOS-0
BASOS-0 ___ MYELOS-0
___ 01:00AM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-1+
MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-1+ TARGET-OCCASIONAL
TEARDROP-OCCASIONAL BITE-OCCASIONAL
___ 01:00AM PLT COUNT-306
___ 01:00AM URINE COLOR-Straw APPEAR-Clear SP ___
___ 01:00AM URINE BLOOD-TR NITRITE-NEG PROTEIN-TR
GLUCOSE-1000 KETONE-150 BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
___ 01:00AM URINE RBC-1 WBC-0 BACTERIA-NONE YEAST-NONE
EPI-0
___ 01:00AM URINE HYALINE-2*
___ 05:30AM BLOOD WBC-3.5* RBC-3.57* Hgb-10.2* Hct-31.7*
MCV-89 MCH-28.7 MCHC-32.3 RDW-15.8* Plt ___
___ 05:30AM BLOOD Glucose-110* UreaN-11 Creat-0.5 Na-138
K-3.5 Cl-109* HCO3-21* AnGap-12
CXR ___: Portable chest radiograph demonstrates no focal
consolidation, pleural effusion, or pneumothorax. The
cardiomediastinal silhouette is normal. IMPRESSION: No acute
cardiopulmonary process.
UCG: Neg
MICRO: Flu swab negative
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. 70/30 26 Units Breakfast
70/30 24 Units Bedtime
2. Lisinopril 2.5 mg PO DAILY
hold for BP less than 100
3. Venlafaxine 225 mg PO DAILY
4. Mirtazapine 30 mg PO HS
Discharge Medications:
1. 70/30 26 Units Breakfast
70/30 24 Units Bedtime
2. Lisinopril 2.5 mg PO DAILY
hold for BP less than 100
3. Mirtazapine 30 mg PO HS
4. Venlafaxine 225 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Diabetic Ketoacidosis
Diabetes Mellitus Type 2
Secondary:
Hypertension
Depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Diabetic ketoacidosis and fever. Evaluate for pneumonia.
COMPARISON: None.
FINDINGS: Portable chest radiograph demonstrates no focal consolidation,
pleural effusion, or pneumothorax. The cardiomediastinal silhouette is
normal.
IMPRESSION: No acute cardiopulmonary process.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: ABD PAIN
Diagnosed with IDDM UNCONTROLLED W/KETOACID, LONG-TERM (CURRENT) USE OF INSULIN, HYPERTENSION NOS
temperature: 101.0
heartrate: 115.0
resprate: 16.0
o2sat: 100.0
sbp: 121.0
dbp: 58.0
level of pain: 0
level of acuity: 3.0 | Ms. ___ is a ___ yof with poorly controlled DM, HTN, depression
and history of alcoholism who presents with nausea, vomiting,
and abdominal pain after recent flu-like illness in the setting
of hyperglycemia and anion-gap metabolic acidosis consistent
with DKA.
# DKA / DM uncontrolled and complicated: She has insulin
dependent diabetes, and has had prior hospitalizations for poor
control including DKA, as well as moderately severe B
nonproliferative diabetic retinopathy. She presented with DKA on
this admission, preceded by a flu-like illness. Her A1C on this
admission was markedly elevated at 11.8%. She was treated with
insulin drip, and was transitioned to her home insulin regimen
(70/30 at 26 units in AM, 24 units in ___ with sliding scale)
when her anion gap acidosis resolved. She was seen by ___ on
this admission, and should have follow up as an outpatient.
Social work was consulted for medication noncompliance in the
setting of poorly controlled blood sugars. Her FSGs on the floor
were well controlled on her home regimen of 70/30 at 26 units in
AM, 24 units in ___. She was discharged on this regimen with
close ___ followup.
# Flu-like illness: She presented with several days of myalgias,
rhinorrhea, and general malaise that preceded her nausea,
vomiting, and abdominal pain. She had a cough in ED, where she
had a temperature measured at 101 on admission. A flu swab was
sent and returned negative for influenza A and B. She was taken
off respiratory precautions, and remained afebrile thereafter.
# Hypertension: stable, continued home lisinopril 2.5mg po daily
# Hx Alcoholism: She reports to having a few drinks on the
weekends, and denies a history of withdrawal or seizures. She
did not have evidence of withdrawal on this admission, and did
not require benzodiazepines. Urine and serum tox screens were
negative on this admission.
# Depression: She has a history of psych hospitalization in ___
for SI, however did not have exhibit suicidal ideation on this
admission. She was continued on her home Mirtazapine 30mg daily,
and Venlafaxine 225mg daily. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Diarrhea, Fever
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ male with primary mediastinal
B-cell lymphoma who presents with 1 day of profuse watery
diarrhea and fever of 102.5.
Per patient, he started having diarrhea on ___ AM, up to every
hour. States he lost count of how many times he had to go but it
was definitely more than 10. Describes stool as very watery,
foul smelling. Reported associated abdominal cramping but no
pain. States his partner at home had an episode of self limited
diarrhea approximately 8 days ago and had attributed it to
something he ate. Denies any other sick contacts. Later
yesterday afternoon, patient stated he had some chills and later
developed a fever up to 102.5 taken orally. He decided to
present to the ED at that time. Of note, patient recently
completed C5 of da-EPOCH-R which started and was discharged on
___. He has not started taking his filgastrim-sndz yet and had
planned to start taking it ___ AM. Endorsed slightly nausea
improved with Zofran at home. Denies any abdominal pain,
constipation, CP, SOB, vomiting, BRBPR, melena, headaches, ___
edema, night sweats, dysuria.
In the ED, initial vitals: 100.7 | 102 | 117/73 | 18 | 97% RA.
Labs with WBC 7.6, ANC 7.52, Hgb 10.3, Plts 139, AST/ALT 103/60,
AP 36, T bili 1.0, Na 134, CO2 21, AG 13, LA 1.2, INR 1.8, ___
19.9. C diff PCR sent and is pending. Flu swab negative for Flu
A/B. UA with rare mucous, trace protein. Blood cx x2, and UCx
sent. EKG with NSR, HR 79, no acute ischemic changes.CXR with no
acute intrathoracic process. Patient given 2L LR, Tylenol 1gm.
Patient admitted to ___ for additional evaluation and
management.
Past Medical History:
PAST ONCOLOGIC HISTORY:
~ ___: Develops new back pain, initially thought to be
musculoskeletal in etiology.
- ___: Develops new left lower quadrant abdominal pain.
- ___: Abdominal pain becomes excruciating, prompting a visit
to his PCP, who recommends a CT abdomen.
- ___: CT abdomen reveals a 3.2 cm mass in the tail of the
pancreas with fat stranding surrounding the splenic vessels and
extending towards the splenic hilum and infiltration of the left
adrenal gland causing splenic vein thrombosis, concerning for
pancreatic adenocarcinoma, as well as lytic lesions in the iliac
wing bilaterally right more than left concerning for metastatic
disease, and a small amount of ascites.
- ___: CT chest shows a soft tissue mass in the
anterosuperior mediastinum abutting the ascending aorta and
superior vena cava.
The mass has imaging characteristics of lymphoma, though
metastatic lesions may have a similar appearance.
- ___: Initial evaluation by Drs. ___ in
Pancreatic ___ clinic. Bone biopsy and mediastinal
biopsy are arranged.
- ___: Bone biopsy reveals involvement by Diffuse Large B
Cell Lymphoma favor non-germinal center type by ___.
A
history of concurrent mediastinal mass is noted; this finding
along with the fibrotic background seen in this biopsy and the
CD23 expression raise the possibility of a metastatic primary
mediastinal (thymic) large B-cell lymphoma. FISH positive for
gain of JAK2 (suggestive of PMBCL) and gain of MYC. There is no
evidence of the IGH/BCL2 gene rearrangement or rearrangements of
the BCL6 and MYC genes.
- ___: Mediastinal mass biopsy reveals a limited core needle
biopsy with extensive crush artifact and atypical large B-cell
infiltrate.
- ___: PET demonstrtes FDG-avid mediastinal mass, pancreatic
mass, mediastinal and pelvic lymphadenopathy, multiple bone
lesions, and small volume ascites.
- ___: Admitted to ___ for expedited treatment initiation.
Port-a-Cath placed. C1D1 da-EPOCH, dose level 1, uncapped
vincristine.
- ___: Discharged to home. Admission further complicated by
isolated INR elevation of uncertain etiology, thought to be most
likely Vitamin K deficiency, given Vitamin K 5 mg PO x 3 days.
- ___: Dose 1 Rituximab.
- ___: Admitted with febrile neutropenia, treated
with intravenous antibiotics and quickly resolved. MRI of the
spine on ___ shows that the T3 spinous process tumor
extended
into the epidural space, with no encroachment on the spinal
cord,
extensive neoplastic involvement of the sacrum and iliac bones
without spinal canal compromise, and degenerative disease at
L4-5
with compression of the L5 nerve roots, as well as large right
anterior mediastinal mass.
- ___: Dose 2 Rituximab. Planned for C2 da-EPOCH on ___
delayed because of persistent thrombocytopenia.
- ___: C2D1 da-EPOCH, dose level 1, uncapped vincristine.
Bactrim stopped because of possible contribution to
thrombocytopenia, Atovaquone initiated for pneumocystis
prophylaxis.
- ___: Lumbar puncture attempted for diagnosis and
prophylactic intrathecal chemotherapy, but unsuccessful.
- ___: Dose 3 Rituximab.
- ___: Planned for C3 da-EPOCH but delayed because of
persistent thrombocytopenia.
- ___: Admitted for C3D1 da-EPOCH, dose level 2,
vincristine
reduced by 25% because of peripheral neuropathy on ___. CT
abdomen to evaluate left upper abdominal pain shows no evidence
of splenic abnormality, with patent splenic vein without
evidence
of thrombosis. It also demonstrates interval improvement in
lytic
lesion through the bilateral iliac wings.
- ___: Undergoes Lumbar Puncture with prophylactic
intrathecal methotrexate x 1. This reveals 2 WBC (69% lymphs), 7
RBCs, TProt 29, and Gluc 70, with normal FISH and flow
cytometry.
- ___: Discharged to home.
- ___: ED visit for post-LP headache, improved with IV fluids
and Fioricet.
- ___: Dose 4 Rituximab.
- ___: Bone Marrow Biopsy performed for persistent moderate
thrombocytopenia. This reveals a mildly hypercellular
myeloid-dominant bone marrow with maturing trilineage
hematopoiesis. The karyotype is 46,XY[20], and FISH is negative
for the MDS panel. Myeloid sequencing reveals no mutations.
- ___: C4D1 da-EPOCH, dose level 1, vincristine dose-reduced
by 50% (for peripheral neuropathy).
- ___: Dose 5 Rituximab.
- ___: da-EPOCH, dose level 2
PAST MEDICAL HISTORY:
Primary Mediastinal B Cell Lymphoma, as above
Social History:
___
Family History:
Extensive family history of rheumatological disease. Mother with
RA. Uncle with SLE. Aunt with history of "multiple benign
tumors" who eventually developed cancer. No other family history
of cancer, lymphoma, or leukemia.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 24 HR Data (last updated ___ @ 337)
Temp: 98.5 (Tm 98.5), BP: 103/57, HR: 74, RR: 16, O2 sat:
100%, O2 delivery: RA, Wt: 197.2 lb/89.45 kg
GENERAL: Lying comfortably in bed, NAD
HEENT: Clear OP without lesions or thrush
EYES: PERRL, anicteric
NECK: supple, no JVD
RESP: No increased WOB, no wheezing, rhonchi or crackles
___: RRR, no murmurs
GI: soft, non-tender, no rebound or guarding, slightly
hyperactive BS
EXT: no edema, warm
SKIN: dry, no obvious rashes
NEURO: alert, fluent speech. PERRL, EOMI.
ACCESS: POC, dressing C/D/I
DISCHARGE PHYSICAL EXAM
VSS
GENERAL: Lying comfortably in bed, NAD, alopecia
HEENT: NC/AT, sclera anicteric, PERRL, EOMI. OP clear. MMM. Sore
right lateral surface of tongue.
RESP: CTAB, no adventitious LS, non-labored.
___: RRR, normal S1/S2. No M/R/G
GI: soft, NT, somewhat distended. No rebound or guarding,
hyperactive BS, no HSM
EXT: WWP. No ___
SKIN: Dry, no rashes or lesions
NEURO: A+Ox3, non-focal
ACCESS: L CW POC without erythema, drainage or tenderness.
Pertinent Results:
ADMISSION LABS
___ 03:52AM BLOOD WBC-2.3* RBC-3.27* Hgb-9.3* Hct-28.4*
MCV-87 MCH-28.4 MCHC-32.7 RDW-18.8* RDWSD-60.6* Plt Ct-42*
___ 03:52AM BLOOD Neuts-94* Lymphs-6* Monos-0* Eos-0*
Baso-0 AbsNeut-2.16 AbsLymp-0.14* AbsMono-0.00* AbsEos-0.00*
AbsBaso-0.00*
___ 03:52AM BLOOD Glucose-85 UreaN-17 Creat-0.7 Na-139
K-3.5 Cl-104 HCO3-23 AnGap-12
___ 03:52AM BLOOD ALT-50* AST-22 LD(LDH)-159 AlkPhos-47
TotBili-1.1
___ 03:52AM BLOOD Albumin-3.5 Calcium-8.4 Phos-4.1 Mg-2.0
DISCHARGE LABS
___ 11:10PM BLOOD WBC-10.0 RBC-3.21* Hgb-9.2* Hct-29.3*
MCV-91 MCH-28.7 MCHC-31.4* RDW-19.1* RDWSD-61.6* Plt Ct-62*
___ 11:10PM BLOOD Neuts-81* Bands-8* Lymphs-5* Monos-5
Eos-0* ___ Myelos-1* NRBC-1.7* AbsNeut-8.90* AbsLymp-0.50*
AbsMono-0.50 AbsEos-0.00* AbsBaso-0.00*
___ 11:10PM BLOOD Glucose-109* UreaN-5* Creat-0.7 Na-144
K-3.9 Cl-105 HCO3-28 AnGap-11
___ 11:10PM BLOOD ALT-46* AST-22 LD(LDH)-230 AlkPhos-82
TotBili-0.3
___ 11:10PM BLOOD Albumin-3.8 Calcium-8.8 Phos-4.4 Mg-2.0
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acyclovir 400 mg PO Q12H
2. Atovaquone Suspension 1500 mg PO DAILY
3. Cetirizine 10 mg PO DAILY:PRN seasonal allergies/bony pain
4. Docusate Sodium 100 mg PO BID:PRN constipation
5. LORazepam 0.5 mg PO Q6H:PRN nausea/vomiting/anxiety/insomnia
6. Senna 8.6 mg PO BID:PRN constipation
7. Vitamin B Complex 1 CAP PO DAILY
8. Vitamin D 1000 UNIT PO DAILY
9. Allopurinol ___ mg PO DAILY
10. Filgrastim-sndz 300 mcg SC ASDIR
11. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting
12. Omeprazole 40 mg PO DAILY
13. OLANZapine 2.5 mg PO DAILY
Discharge Medications:
1. Acyclovir 400 mg PO Q12H
2. Allopurinol ___ mg PO DAILY
3. Atovaquone Suspension 1500 mg PO DAILY
4. Cetirizine 10 mg PO DAILY:PRN seasonal allergies/bony pain
5. LORazepam 0.5 mg PO Q6H:PRN nausea/vomiting/anxiety/insomnia
6. OLANZapine 2.5 mg PO DAILY
7. Omeprazole 40 mg PO DAILY
8. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting
9. Vitamin B Complex 1 CAP PO DAILY
10. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis
==================
primary mediastinal B cell lymphoma
diarrhea
fever
splenic infarct
nausea
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT ABD AND PELVIS WITH CONTRAST ___
INDICATION: ___ year old man with DLBCL admitted w/ fever and GI sxs //
ongoing profuse diarrhea w/ intermittent abdominal discomfort, evaluate for
colitis or other intra-abdominal infection
TECHNIQUE: Multidetector CT images of the abdomen and pelvis were obtained
with oral and intravenous contrast. Sagittal and coronal reformations were
also performed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 9.3 mGy (Body) DLP = 1.9
mGy-cm.
2) Stationary Acquisition 14.2 s, 0.2 cm; CTDIvol = 242.8 mGy (Body) DLP =
48.6 mGy-cm.
3) Spiral Acquisition 8.3 s, 53.9 cm; CTDIvol = 18.0 mGy (Body) DLP = 959.2
mGy-cm.
Total DLP (Body) = 1,010 mGy-cm.
COMPARISON: Prior studies available from ___.
FINDINGS:
Central venous catheter terminates at the cavoatrial junction. Visualized
lung bases appear clear. No pleural effusions.
No focal liver lesions are identified. There is no biliary dilatation.
Phrygian cap along the gallbladder.Pancreas is unremarkable. Adrenals appear
normal. The spleen is again enlarged. It measures up to 18.5 cm in length,
essentially unchanged.
Spleen shows a new area of infarction (7:15) which is partly liquified.
No evidence for stones, solid masses, or hydronephrosis involving either
kidney.
The stomach is nondistended. Small bowel is unremarkable. Mildly prominent
fluid content along the colon but without dilatation, wall thickening or
pericolonic inflammatory changes.
Appendix appears normal. Small focus of air in right anterior subcutaneous
fat suggests injects near site.
Prostate is mildly enlarged with central hypertrophy. Seminal vesicles
appear normal. Bladder is unremarkable. Right mid ureter is again slightly
prominent in caliber. There is no lymph adenopathy or free fluid. There is a
large gastro omental collateral that is unchanged and probably due to a
collateral pathway associated with marked narrowing of the splenic vein
although it remains patent.
There are no suspicious bone lesions. Bones appear demineralized. Sclerotic
areas in the pelvis demonstrate no short-term change. There is a slight new
compression fracture of the superior endplate of T12 without healing, new
since ___. Late ___.
IMPRESSION:
1. Nonspecific mildly prominent fluid content along the colon without
specific evidence for colitis.
2. Moderately enlarged spleen, unchanged in size, but with new splenic
infarct.
3. New mild superior endplate compression fracture of T12 since late ___.
Radiology Report
EXAMINATION: CT angiography of the abdomen and pelvis.
INDICATION: Primary mediastinal B-cell lymphoma with splenic infarct.
TECHNIQUE: Following acquisition of a noncontrast scan of the abdomen,
multidetector CT images of the abdomen were obtained in arterial and portal
venous phases following intravenous contrast administration. The portal
venous phase images include the pelvis. In addition, delayed phase images of
the abdomen are included at 16.3 minutes. Sagittal and coronal reformations
of the arterial and portal venous phase images are included as well as a
coronal MIP image. This study also includes multiplanar MIP and volume high
for an rendered reformations of the arterial and venous vasculature of the
abdomen.
DOSE: Acquisition sequence:
1) Spiral Acquisition 5.1 s, 33.4 cm; CTDIvol = 5.7 mGy (Body) DLP = 185.5
mGy-cm.
2) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 9.3 mGy (Body) DLP = 1.9
mGy-cm.
3) Stationary Acquisition 21.3 s, 0.2 cm; CTDIvol = 362.4 mGy (Body) DLP =
72.5 mGy-cm.
4) Spiral Acquisition 4.4 s, 28.3 cm; CTDIvol = 18.6 mGy (Body) DLP = 515.1
mGy-cm.
5) Spiral Acquisition 8.6 s, 55.6 cm; CTDIvol = 17.6 mGy (Body) DLP = 969.7
mGy-cm.
6) Spiral Acquisition 4.4 s, 28.3 cm; CTDIvol = 18.6 mGy (Body) DLP = 515.1
mGy-cm.
Total DLP (Body) = 2,260 mGy-cm.
COMPARISON: CT performed on the prior day and ___.
FINDINGS:
Venous catheter terminates at the cavoatrial junction. Visualized lung bases
appear clear.
No focal liver lesions are identified. There is no biliary dilatation.
Phrygian cap along the gallbladder, consistent with a normal variant.
Pancreas appears normal. Spleen is again enlarged, measuring up to 17.9 cm in
length without short-term change. An infarct in the spleen is also unchanged.
Adrenals appear normal.
Stomach is nondistended. Small bowel shows mildly prominent fluid content
distally, and similar to the recent prior study, there is mildly prominent
fluid content along the whole colon, but without wall thickening or associated
inflammatory changes.
Prostate is again enlarged with central hypertrophy. Distal ureters, seminal
vesicles and bladder appear normal. There is no ascites. There is no
discrete lymphadenopathy, only stable soft tissue thickening in the splenic
hilum which is unchanged since at least ___.
There is similar narrowing of the mid splenic vein and probably multifocal
narrowings among splenic venous branches at the hilum that are sequela of
prior lymphoma at the site and thrombosis that has resolved. Owing to this
circumstance, there are numerous collateral vessels draining the spleen
including extensive gastric fundal varices, without short-term change. There
also small paraesophageal varices and a large gastro omental collateral from
the splenic hilar venous branches in the hilum to the superior mesenteric
vein.
Bony structures are unchanged, including bilateral iliac lesions. Slight
superior compression deformity of T12 is unchanged.
IMPRESSION:
1. No evidence of splenic venous thrombosis. Unchanged sequela of prior
splenic venous thrombosis and lymphoma in the splenic hilum, however, with
narrowed venous structures and associated collateral flow including gastric
varices.
2. Unchanged splenic infarct. Stable moderate splenomegaly.
3. Mildly prominent fluid content along the distal small bowel and colon,
similar to recent prior findings, nonspecific.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Diarrhea, Fever
Diagnosed with Fever, unspecified
temperature: 100.7
heartrate: 102.0
resprate: 18.0
o2sat: 97.0
sbp: 117.0
dbp: 73.0
level of pain: 0
level of acuity: 3.0 | Mr. ___ is a ___ male with
primary mediastinal B-cell lymphoma who presents with 1 day of
profuse watery diarrhea and fever of 102.5 in setting of recent
chemotherapy.
ACUTE CONDITIONS
=====================
#DIARRHEA & FEVER (resolved): afebrile since ___. Suspect
most likely related to gastroenteritis given sick exposure.
Extensive infectious work up negative. In the context of recent
chemotherapy and nadir, he was started on Cefepime (D1:
___ as well as Flagyl (D1: ___. CT
A/P to evaluate for possible colitis negative. Obtained CTA abd
to assess if thrombosis causing diarrhea (splenic thrombosis
secondary to lymphoma on diagnosis) although neg for new
thrombosis with stable previous thrombosis (unlikely cause of
diarrhea).
-changed Imodium/Lomotil to prn with diarrhea improvement ___,
diarrhea resolved completely upon discharge ___
-off Cefepime and Flagyl as above with count recovery
-stool culture data negative
-CMV VL negative
#SPLENIC INFARCT.
#SPLENIC VEIN THROMBOSIS: New splenic infact seen on CT A/P on
___. As splenic infarcts are typically arterial in nature,
obtained TTE ___ and no vegetations are seen. To further
evaluate for splenic or mesenteric clots, obtained multiphasic
CTA of the abd which shown unchanged sequela of thrombosis
(since
diagnosis) but no new thrombosis therefore unlikely to be
causing
acute diarrhea as above.
-monitor for now, no anticoagulation per primary team due to TCP
and discussed with Dr ___ specialist
#PRIMARY MEDIASTINAL B-CELL LYMPHOMA: PET:3 ___ showed CR.
For his systemic therapy, he underwent C5 DA-EPOCH ___ now
in
nadir. Regarding his CNS prophylaxis, given his
extensive marrow involvement and extranodal disease, he will
provisionally receive prophylactic high-dose methotrexate x2-3
doses following completion of his primary therapy. Of note, he
received x1 dose of intrathecal methotrexate.
-off neupogen ___ with count recovery
-Continue ACV 400mg BID for HSV/VZV prophylaxis
-Continue Mepron for PJP prophylaxis.
#PANCYTOPENIA: recovering post last cycle of EPOCH. Persistent
thrombocytopenia felt to be related to ongoing mild splenomegaly
as well as recent chemotherapy.
-Transfuse if plts < 10 and/or hgb < 7
-off neupogen as above
CHRONIC/STABLE/RESOLVED CONDITIONS
=======================================
#NAUSEA: Resolved. No recent vomiting. Suspect due to GI
infection as above though could also represent delayed CINV. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Iron / adhesive tape
Attending: ___.
Chief Complaint:
Chest tightness
Atrial fibrillation with RVR
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w/ hx of CAD (s/p ___ DES to RCAx3, distal RCAx1,
marginal branchx1), atrial fibrillation s/p cardioversion (___)
on warfarin, HTN, DM, ESRD s/p renal transplant, and presenting
with RVR, chest pressure without hemodynamic instability.
Patient has been experiencing three days of chest pain beginning
___. Pain ranges from a ___, with radiation
to the back, worsened by exertion. Initially relieved by nitro
x1 on Wednseday but pain returned on ___. Associated with
SOB and lightheadedness but no diaphoresis. He additionally
denies any fevers/chills, nausea/vomiting, abd pain,
diarrhea/constipation, or dysuria. He presented to ___ for
outpatient follow-up and was found to be atrial fibrillation
with HR in 110s.
Patient was recently admitted to ___, 2 weeks ago for a-fib
with RVR that was managed with sedated cardioversion and
diltiazem. Stay was complicated by NSTEMI with DES placed on ___
RCAx3 and again on ___ RCAx1 marginal arteryx1. Patient was
discharged on ___ in sinus rhythm with no chest pain on
coumadin, spirin 81mg and plavix.
-In the ED initial vitals were: T: 98.1 HR: 116 BP: 109/80 RR:
16 SO2: 99% RA.
-EKG showed atrial fibrillation with ventricular rate of 133
-Labs/studies notable for subtherapetuic INR 1.8, Cr 1.6 (from
1.3 on discharge), trop 0.19 (0.50 ___. CXR shows no acute
cardiopulmonary process.
-Patient was given: Diltiazem 15 mg IV (h/o of depressed EF last
admission), started on IV heparin gtt, 25 mg metop tartrate x 1,
SL nitro 0.4 mg.
-Cardiology was consulted and recommended continuing
antiplatelet, heparinizing given INR subtherapeutic, giving
metop 25 mg q6h, cycling trops, and admission to cardiology.
On the floor, he appears comfortable, with no acute comlaints of
chest pain, chest tightness.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope, or presyncope.
On further review of systems, denies fevers or chills. Denies
any prior history of stroke, TIA, deep venous thrombosis,
pulmonary embolism, bleeding at the time of surgery, myalgias,
joint pains, cough, hemoptysis, black stools or red stools.
Denies exertional buttock or calf pain. All of the other review
of systems were negative.
Past Medical History:
1. CARDIAC RISK FACTORS:
HYPERCHOLESTEROLEMIA
HYPERTENSION
DIABETES TYPE II
2. CARDIAC HISTORY:
- PUMP FUNCTION: >55%
- PACING/ICD: None.
- CHRONIC ANGINA
3. OTHER PAST MEDICAL HISTORY:
CHRONIC OBSTRUCTIVE PULMONARY DISEASE
h/o ERSD on hemodialysis since ___ bilateral AV fistulae
s/p cadaveric renal transplant (R) anastomosed to right iliac
artery/vein on ___
IMPOTENCE
LUNG NODULE
OSTEOPENIA TOE FRACTURE
BILATERAL KNEE PAIN (RIGHT >LEFT)
ENLARGED LYMPH NODES
DEPRESSION
ALLERGIC RHINITIS H/O GI ULCER
H/O TOE FRACTURE
H/O GASTROINTESTINAL BLEEDING
Social History:
___
Family History:
Significant for hypertension in his mother. A granddaughter had
an unspecified cardiomyopathy at age ___ that required heart
transplant. Father with diabetes and prostate Ca. Mother with
DM. Brother with 3x CVAs.
Physical Exam:
PHYSICAL EXAM ON ADMISSION:
===========================
VS: Afebrile, Tachycardic to 110s, BPs 100s-110s/50s-60s, RR:
18, >95RA
General: NAD
HEENT: NCAT, PERRL, EOMI,
Neck: no e/o of JVP distension.
CV: irregular rhythm, not tachycardic +II/VI systolic murmur
greatest at ___
Lungs: CTABL no w/c/r
Abdomen: soft, NDNT, no ttp on right lower abdomen.
Ext: non edemaatous,
Neuro: CNII-XII intact, grossly non-focal, full strength Upper
extremities and lower extremities (___), sensation normal.
Skin: +palpable former fistula, no bruit
PHYSICAL EXAM ON DISCHARGE:
===========================
Vitals: T Afebrile, HR: 80-90s BP: 100s-120s/60s-70s RR: ___
>95RA.
General: AOx3, NAD.
HEENT: NCAT, PERRL, EOMI, mucous membranes moist.
NECK: Supple, no appreciable JVD.
CV: sinus, +II/VI systolic murmur greatest at ___
LUNGS: Clear to auscultation bilaterally with no crackles,
wheezes, or rhonchi.
Abdomen: soft, NDNT, nontender to palpation at prior kidney
transplant on Rt side.
Ext: no ___ edema, wwp, +DPP
Neuro: CNII-XII intact, grossly non-focal, UEs + LEs ___
strength b/l.
Skin: +palpable former fistula, no bruit
Pertinent Results:
Labs on Admission
=================
___ 03:26PM BLOOD WBC-5.8 RBC-4.07* Hgb-11.7* Hct-37.3*
MCV-92 MCH-28.7 MCHC-31.4* RDW-12.9 RDWSD-43.2 Plt ___
___ 03:26PM BLOOD Plt ___
___ 04:55PM BLOOD ___ PTT-34.0 ___
___ 03:26PM BLOOD Glucose-218* UreaN-29* Creat-1.6* Na-135
K-5.0 Cl-102 HCO3-21* AnGap-17
___ 03:26PM BLOOD cTropnT-0.19*
___ 01:13AM BLOOD CK-MB-4 cTropnT-0.18*
___ 10:35AM BLOOD CK-MB-3 cTropnT-0.18*
___ 03:57AM BLOOD CK-MB-2 cTropnT-0.13*
___ 09:20AM BLOOD CK-MB-2 cTropnT-0.12*
___ 09:42AM BLOOD Calcium-9.8 Phos-3.1 Mg-1.5*
___ 09:42AM BLOOD tacroFK-4.7*
Labs at Discharge
=================
___ 09:05AM BLOOD WBC-4.9 RBC-4.23* Hgb-12.1* Hct-38.4*
MCV-91 MCH-28.6 MCHC-31.5* RDW-13.1 RDWSD-43.6 Plt ___
___ 09:05AM BLOOD Plt ___
___ 09:05AM BLOOD ___ PTT-64.0* ___
___ 09:05AM BLOOD Glucose-154* UreaN-28* Creat-1.7* Na-134
K-4.0 Cl-99 HCO3-23 AnGap-16
___ 09:05AM BLOOD Calcium-10.0 Phos-3.2 Mg-1.8
___ 09:05AM BLOOD tacroFK-5.9
___ 09:20AM BLOOD tacroFK-5.5 rapmycn-6.0
Pertinent studies:
==================
CXR ___:
1. No acute cardiopulmonary process.
2. Stable prominence of right pulmonary artery is suggestive of
pulmonary
artery hypertension.
3. Stable mild cardiomegaly. No pulmonary edema.
4. Stable left lung 10 mm pulmonary nodule, unchanged from ___
and better
assessed on CT chest from ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler ___ PUFF IH Q6H:PRN sob
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. Enalapril Maleate 2.5 mg PO DAILY
5. Sirolimus 1 mg PO DAILY
6. Tacrolimus 0.5 mg PO QAM
7. Tacrolimus 1 mg PO QHS
8. Doxazosin 4 mg PO DAILY
9. Multivitamins 1 TAB PO DAILY
10. amLODIPine 5 mg PO DAILY
11. Warfarin 3 mg PO DAILY16
12. PredniSONE 2.5 mg PO DAILY
13. Tiotropium Bromide 1 CAP IH DAILY
14. Fluticasone Propionate NASAL 1 SPRY NU DAILY
15. Furosemide 20 mg PO DAILY
16. ZEMplar (paricalcitol) 1 mcg oral DAILY
17. Clopidogrel 75 mg PO DAILY
18. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
19. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN angina
20. Pantoprazole 40 mg PO Q24H
21. Metoprolol Succinate XL 12.5 mg PO DAILY
22. Humalog 3 Units Breakfast
Levemir 6 Units Bedtime
23. Calcium 500 + D (D3) (calcium carbonate-vitamin D3) 500
mg(1,250mg) -125 unit oral DAILY
24. Psyllium Powder 1 PKT PO DAILY:PRN constipation
Discharge Medications:
1. Amiodarone 200 mg PO DAILY
2. Metoprolol Succinate XL 150 mg PO QHS
3. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
4. Pantoprazole 40 mg PO Q12H
5. Warfarin 2 mg PO DAILY
6. Albuterol Inhaler ___ PUFF IH Q6H:PRN sob
7. Aspirin 81 mg PO DAILY
8. Atorvastatin 80 mg PO QPM
9. Calcium 500 + D (D3) (calcium carbonate-vitamin D3) 500
mg(1,250mg) -125 unit oral DAILY
10. Clopidogrel 75 mg PO DAILY
11. Doxazosin 4 mg PO DAILY
12. Fluticasone Propionate NASAL 1 SPRY NU DAILY
13. Furosemide 20 mg PO DAILY
14. Humalog 3 Units Breakfast
Levemir 6 Units Bedtime
15. Multivitamins 1 TAB PO DAILY
16. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN angina
17. PredniSONE 2.5 mg PO DAILY
18. Psyllium Powder 1 PKT PO DAILY:PRN constipation
19. Sirolimus 1 mg PO DAILY
20. Tacrolimus 0.5 mg PO QAM
21. Tacrolimus 1 mg PO QHS
22. Tiotropium Bromide 1 CAP IH DAILY
23. ZEMplar (paricalcitol) 1 mcg oral DAILY
24. HELD- Enalapril Maleate 2.5 mg PO DAILY This medication was
held.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Atrial Fibrillation w/ RVR
Chest pressure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: Chest radiograph
INDICATION: ___ with chest pain. Assess for pneumothorax.
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph ___, CT chest ___
FINDINGS:
The lungs are hyperinflated and clear. No pleural effusion or pneumothorax.
Prominence of the right pulmonary artery is stable. Again seen is a 10 mm
nodular opacity projecting over the anterior left sixth rib which is unchanged
dating back to ___. Stable mild cardiomegaly. Aortic arch, mitral
annular disease and coronary artery calcifications are present. Mediastinal
contour and hila are unremarkable.
IMPRESSION:
1. No acute cardiopulmonary process.
2. Stable prominence of right pulmonary artery is suggestive of pulmonary
artery hypertension.
3. Stable mild cardiomegaly. No pulmonary edema.
4. Stable left lung 10 mm pulmonary nodule, unchanged from ___ and better
assessed on CT chest from ___.
Gender: M
Race: HISPANIC/LATINO - PUERTO RICAN
Arrive by WALK IN
Chief complaint: Chest pain
Diagnosed with Non-ST elevation (NSTEMI) myocardial infarction
temperature: 98.1
heartrate: 116.0
resprate: 16.0
o2sat: 99.0
sbp: 109.0
dbp: 80.0
level of pain: 2
level of acuity: 2.0 | Mr. ___ is a ___ w/ hx of CAD (s/p ___ PCIx5), atrial
fibrillation s/p TEE/DC-cardioversion (___) on warfarin, HTN,
DM, ESRD s/p renal transplant, who presented to the hospital
within 7 days of being discharged with Atrial fibrillation with
RVR and chest pressure.
# Atrial fibrillation with RVR (CHADS 3):
Mr. ___ initially presented during the previous admission
with Atrial fibrillation with RVR. He underwent DC cardioversion
on ___ and was discharged ___ on metoprol 12.5mg XL and
warfarin 3mg. He represented to us within several days of being
discharged as he was found to have atrial fibrillation with RVR
at his primary care visit. The etiology for the failed
cardioversion is unclear. He did not have any infection. TSH on
___ was 0.8mg. Given the failed cardioversion, his rates during
this hospitalization were controlled with metoprolol 150mg
daily. In consultation with his primary cardiologist, he was
started on amiodarone gtt and was transitioned to amiodarone PO
(for loading) at discharge. After being loaded, his consistent
amiodarone dosing would be 200 mg daily. He was also on warfarin
anticoagulation; however, at presentation, his anticoagulation
was sub-therapeutic. He was bridged using heparin to warfarin.
Given that amiodarone increases the concentration of warfarin,
he was discharged on warfarin 2mg daily. His INR at discharge
was 2.1. At discharge, his heart rates were ~70s-90s, with
occasional asymptomatic AFib with RVR to 140s. As such, he
received ___ of Hearts monitor to evaluate his burden of
atrial fibrillation disease. He will need to follow up with the
results at his cardiology appointment.
# Chest Pressure:
He presented with atypical and non-exertional chest pain that
was also not related to the ventricular rates. He was evaluated
with initial EKG, troponins, and CK-MB. The CK-MB was not
elevated at 4 and continued to remain flat, and the troponin was
downtrending (from 0.50 at previous discharge to 0.12 on ___
with no significant EKG changes. There was some concern that
this could have been related to atrial fibrillation, but he
frequently had chest pain when his ventricular rates were in
___. He complained of point tenderness worsened with
palpation, so he was treated for musculoskeletal chest pain with
acetaminophen. He also complained of GERD-like symptoms, so he
was discharged with pantoprazole 40mg BID. Given his extensive
history of coronary artery disease, his Imdur was increased to
60 mg daily. At discharge, he did not complain of chest pain,
and he remained symptom free.
#Vasovagal Symptoms:
On ___, he had a presyncopal episode with nausea and
prodromal symptoms of blurry vision and diaphoresis, but without
chest pain. The symptoms lasted less than 1 minute and resolved
without any intervention. An EKG showed no changes from prior
EKGs and troponins were downtrending, with MB unchanged. His
presyncope was likely vasovagal presyncope. It did not occur and
at discharge he was without any vasovagal symptoms.
# GERD:
On several occasions, Mr. ___ complained of pain in the
___ his chest that worsened with laying back on his
stomach after eating. The pain improved without any
intervention. His pantoprazole was increased to 40 mg BID. At
discharge, he was symptom-free.
# Systolic Heart Failure:
He has evidence of systolic heart failure with reduced EF of
45%. In the setting of increasing metoprolol doses, the
enalapril was held. At discharge, blood pressures were notable
for SBPs ___.
# HTN:
Was initially controlled with amlodipine. However, amlodipine
was discontinued as his blood pressures at discharge were as
above. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
adhesive tape / Bactrim / Monurol
Attending: ___.
Major Surgical or Invasive Procedure:
None
attach
Pertinent Results:
ADMISSION LABS:
================
___ 08:35PM OTHER BODY FLUID ___
___ 05:23PM ___
___ 05:08PM ___ UREA ___
___ TOTAL ___ ANION ___
___ 05:08PM ___ this
___ 05:08PM ALT(SGPT)-65* AST(SGOT)-79* ALK ___ TOT
___
___ 05:08PM ___
___ 05:08PM ___
___ 05:08PM ___
___
___ 05:08PM ___
___
___
___ 05:08PM ___
___
___ REVI
___ 05:08PM PLT ___ PLT ___
___ 05:08PM ___ ___
___ 12:30PM UREA ___
___ TOTAL ___ ANION ___
___ 12:30PM ALT(SGPT)-69* AST(SGOT)-81* LD(LDH)-513* ALK
___ TOT ___
___ 12:30PM ___
___
___ 12:30PM ___
___ 12:30PM ___
___
___ 12:30PM ___
___ IM ___
___
___ 12:30PM PLT ___
PERTINENT INTERVAL LABS:
========================
___ 12:46AM BLOOD ___
___ Plt ___
___ 12:38AM BLOOD ___
___ Plt ___
___ 02:09AM BLOOD ___
___ Plt ___
___ 12:46AM BLOOD ___
___
___
___ 12:38AM BLOOD ___
___
___
___ 05:08PM BLOOD ___
___
___
___ 12:46AM BLOOD ___
___
___ 12:38AM BLOOD ___
___
___ 06:01AM BLOOD ___
___
___ 02:09AM BLOOD ___
___
___ 05:08PM BLOOD ___
___
___ 12:46AM BLOOD ___ LD(LDH)-467* ___
___
___ 12:38AM BLOOD ___ LD(LDH)-439* ___
___
___ 02:09AM BLOOD ___
___ 12:46AM BLOOD ___
___ 12:38AM BLOOD ___
___ 02:09AM BLOOD ___
___ 12:30PM BLOOD ___
DISCHARGE LABS:
================
___ 09:28PM BLOOD ___
___ Plt ___
___ 09:28PM BLOOD ___
___
___
___ 09:28PM BLOOD ___
___
___ RBC ___
REVI
___ 09:28PM BLOOD ___
___
___ 09:28PM BLOOD ___ LD(LDH)-431* ___
___
___ 09:28PM BLOOD ___
MICRO:
======
___ 4:25 pm Rapid Respiratory Viral Screen & Culture
Source: Nasopharyngeal swab.
Respiratory Viral Culture (Final ___:
No respiratory viruses isolated.
Culture screened for Adenovirus, Influenza A & B, Parainfluenza
type
1,2 & 3, and Respiratory Syncytial Virus..
Detection of viruses other than those listed above will only
beperformed on specific request. Please call Virology at
___ within 1 week if additional testing is needed.
Respiratory Viral Antigen Screen (Final ___:
Negative for Respiratory Viral Antigen.
Specimen screened for: Adeno, Parainfluenza 1, 2, 3, Influenza
A, B, and RSV by immunofluorescence.
Refer to respiratory viral culture and/or Influenza PCR (results
listed under "OTHER" tab) for further information..
BCX ___ x2 NGTD
MRSA SCREEN (Final ___: No MRSA isolated.
Legionella Urinary Antigen (Final ___: NEGATIVE FOR
LEGIONELLA SEROGROUP 1 ANTIGEN.
IMAGING:
=========
CT A/P ___
IMPRESSION:
1. Finding suggest right middle lobe pneumonia.
2. Mildly distended gallbladder with stones but without
specific evidence for acute cholecystitis.
3. Findings concerning for chronic liver disease.
4. Moderate bladder distension, which might explain mild new
right
hydroureter.
CXR ___
IMPRESSION:
Opacities at the right lung base which may be due to aspiration,
pneumonia,
possibly asymmetric edema; less typical for atelectasis.
Suspected mild
coinciding vascular congestion.
RUQUS ___
IMPRESSION:
No features of cholecystitis.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acyclovir 400 mg PO Q12H
2. Atovaquone Suspension 750 mg PO DAILY
3. Escitalopram Oxalate 20 mg PO DAILY
4. Fluticasone Propionate NASAL 1 SPRY NU BID
5. FoLIC Acid 1 mg PO DAILY
6. Gabapentin 400 mg PO BID
7. HYDROmorphone (Dilaudid) ___ mg PO Q8H:PRN Pain - Moderate
8. Isavuconazonium Sulfate 372 mg PO DAILY
9. Levothyroxine Sodium 112 mcg PO DAILY
10. Lidocaine 5% Patch 1 PTCH TD QAM
11. LORazepam ___ mg PO QHS:PRN inaomnia
12. Mycophenolate Mofetil 500 mg PO BID
13. Nitrofurantoin (Macrodantin) 100 mg PO DAILY
14. Omeprazole 20 mg PO DAILY
15. PredniSONE 7.5 mg PO DAILY
16. Promethazine 12.5 mg PO Q6H:PRN nausea
17. Jakafi (ruxolitinib) 5 mg oral BID
18. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild/Fever
19. Bisacodyl 10 mg PO DAILY:PRN Constipation - Second Line
20. calcium citrate 250 mg calcium oral BID
21. Vitamin D 1000 UNIT PO DAILY
22. Docusate Sodium 100 mg PO DAILY:PRN Constipation - First
Line
23. Loratadine 10 mg PO DAILY
24. Magnesium Oxide 140 mg PO DAILY
25. Polyethylene Glycol 17 g PO BID:PRN Constipation - Third
Line
26. Artificial Tears ___ DROP BOTH EYES Q4H:PRN itching
27. Senna 8.6 mg PO DAILY:PRN Constipation - First Line
Discharge Medications:
1. LevoFLOXacin 750 mg PO DAILY Duration: 3 Doses
One pill daily from ___
RX *levofloxacin 750 mg 1 tablet(s) by mouth once daily Disp #*3
Tablet Refills:*0
2. Vancomycin Oral Liquid ___ mg PO/NG BID
RX *vancomycin 50 mg/mL 125 mg by mouth twice a day Refills:*0
RX *vancomycin 50 mg/mL 125 mg by mouth twice a day Refills:*0
3. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild/Fever
4. Acyclovir 400 mg PO Q12H
5. Artificial Tears ___ DROP BOTH EYES Q4H:PRN itching
6. Atovaquone Suspension 750 mg PO DAILY
7. Bisacodyl 10 mg PO DAILY:PRN Constipation - Second Line
8. calcium citrate 250 mg calcium oral BID
9. Docusate Sodium 100 mg PO DAILY:PRN Constipation - First
Line
10. Escitalopram Oxalate 20 mg PO DAILY
11. Fluticasone Propionate NASAL 1 SPRY NU BID
12. FoLIC Acid 1 mg PO DAILY
13. Gabapentin 400 mg PO BID
14. Isavuconazonium Sulfate 372 mg PO DAILY
15. Jakafi (ruxolitinib) 5 mg oral BID
16. Levothyroxine Sodium 112 mcg PO DAILY
17. Lidocaine 5% Patch 1 PTCH TD QAM
18. Loratadine 10 mg PO DAILY
19. LORazepam ___ mg PO QHS:PRN inaomnia
20. Magnesium Oxide 140 mg PO DAILY
21. Mycophenolate Mofetil 500 mg PO BID
22. Omeprazole 20 mg PO DAILY
23. Polyethylene Glycol 17 g PO BID:PRN Constipation - Third
Line
24. PredniSONE 7.5 mg PO DAILY
25. Promethazine 12.5 mg PO Q6H:PRN nausea
26. Senna 8.6 mg PO DAILY:PRN Constipation - First Line
27. Vitamin D 1000 UNIT PO DAILY
28. HELD- HYDROmorphone (Dilaudid) ___ mg PO Q8H:PRN Pain -
Moderate This medication was held. Do not restart HYDROmorphone
(Dilaudid) until you talk to your oncologist. This was weaned
during hospitalization.
29. HELD- Nitrofurantoin (Macrodantin) 100 mg PO DAILY This
medication was held. Do not restart Nitrofurantoin (Macrodantin)
until you finish your levofloxacin. Pls restart when you are
finished with your course of levofloxacin.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
===================
Pneumonia
Hypoxic respiratory failure
Sepsis
Secondary diagnosis:
====================
Diarrhea
Active GVHD of liver
CVID
History of recurrent diffuse large ___ lymphoma
History of CMV VL detection
History of recurrent C. diff
T12 compression fracture
hypothyroidism
Depression
GERD
Malnutrition
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: Chest radiograph, portable AP semi-upright.
INDICATION: Shortness of breath.
COMPARISON: CT is available from ___.
FINDINGS:
Central venous catheter terminates in the right atrium. Patient is status
post mitral valve replacement. Lung volumes are very low. Cardiac,
mediastinal and hilar contours appear stable. There is no definite pleural
effusion. No visible pneumothorax. Patchy nonspecific left basilar opacity,
although most frequently this would be due to atelectasis as there is some
chronic scarring at the site. Right basilar opacity is patchy and may be due
to newly developed pneumonia or aspiration since the recent prior CT of the
abdomen, which depicted the lung bases. Mild vascular congestion.
IMPRESSION:
Opacities at the right lung base which may be due to aspiration, pneumonia,
possibly asymmetric edema; less typical for atelectasis. Suspected mild
coinciding vascular congestion.
RECOMMENDATION(S): Short-term follow-up repeat radiographs may be helpful.
Radiology Report
EXAMINATION: CT ABD AND PELVIS WITH CONTRAST ___
INDICATION: NO_PO contrast; History: ___ with abdominal pain. NO_PO contrast
// cholecystitis? cholangitis?
TECHNIQUE: Abdominal pain.
DOSE: Acquisition sequence:
1) Stationary Acquisition 4.0 s, 0.5 cm; CTDIvol = 19.3 mGy (Body) DLP =
9.6 mGy-cm.
2) Spiral Acquisition 5.9 s, 46.6 cm; CTDIvol = 13.2 mGy (Body) DLP = 613.4
mGy-cm.
Total DLP (Body) = 623 mGy-cm.
COMPARISON: ___.
FINDINGS:
Patient is status post mitral valve replacement. Heart is mildly enlarged.
Opacities at each lung base suggest atelectasis, but right middle lobe opacity
with air bronchograms raises suspicion for pneumonia.
Morphological changes of the liver suggest fibrosis/cirrhosis including
enlargement of the left lateral segments and caudate with respect to the right
lobe which is moderately striking. No focal liver lesions are identified on
this monophasic portal venous examination. There is no biliary dilatation.
Gallbladder shows small layering stones, but is otherwise unremarkable. The
pancreas appears normal. Patient is status post splenectomy. Adrenals are
unremarkable. Very small simple appearing cyst along the upper pole of the
right kidney. Mild scarring along the left upper pole. These findings are
unchanged. In each case there is again prominent extrarenal pelvis, which is
usually a normal variant. However, in this case the right ureter is also
mildly dilated. This may be secondary to bladder distension.
The stomach and small bowel appear normal. The extent of stool along the
whole colon is moderately prominent. Hyperdense pill fragments are found
within the colon. Appendix is identified and appears normal.
Bladder is moderately distended. Again observed are moderate-sized left
gonadal varices. Uterus and adnexa are otherwise unremarkable. Vascular
calcification is mild. Major vascular structures appear widely patent. There
is no lymphadenopathy, free air, or free fluid. Diastasis rectus.
Bones appear demineralized. There are no suspicious bone lesions. Sclerotic
focus in the left acetabulum is again consistent with a bone island. Moderate
degenerative changes affect lower lumbar facets. Compression deformities of
the T12 and L1 vertebral bodies are stable including
kyphoplasty/vertebroplasty changes in T12.
IMPRESSION:
1. Finding suggest right middle lobe pneumonia.
2. Mildly distended gallbladder with stones but without specific evidence for
acute cholecystitis. Ultrasound may be helpful to evaluate further, however,
if that remains a potential concern based on clinical grounds. Owing to its
deep location, however, it would be difficult to assess for ___ sign
regardless, however.
3. Findings concerning for chronic liver disease.
4. Moderate bladder distension, which might explain mild new right
hydroureter.
Radiology Report
EXAMINATION: US ABD LIMIT, SINGLE ORGAN
INDICATION: ___ year old woman with gallbladder distension, cholelithiasis,
abd pain // CBD dilation, wall edema, e/o cholecystitis
TECHNIQUE: Grey scale and color Doppler ultrasound images of the right upper
quadrant were obtained.
COMPARISON: Prior CT abdomen pelvis done ___
FINDINGS:
LIVER: No suspicious focal lesions on limited liver ultrasound.
BILE DUCTS: There is no intrahepatic biliary dilation.
CHD: 2 mm
GALLBLADDER: Is partially collapsed. Multiple sub 5 mm cholesterol polyps are
noted. Dependent small hyperdense calculi/gravel are noted in the
gallbladder. No wall thickening. No sonographic ___.
IMPRESSION:
No features of cholecystitis.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Fever, Weakness
Diagnosed with Pneumonia, unspecified organism
temperature: 101.6
heartrate: 80.0
resprate: 26.0
o2sat: 95.0
sbp: 103.0
dbp: 59.0
level of pain: 0
level of acuity: 2.0 | Patient Summary:
================
___ year old woman with history of Hodgkins lymphoma s/p
allogenic SCT (___) c/b GVHD of liver on mycophenolate, Jakafi,
and low dose prednisone, hypogammaglobulinemia, recurrent
infections inc hx aspergillosis, UTI's, C. diff, who initially
presented to the ED with fevers (101.6), hypotension (103/59)
pleuritic chest pain, SOB with 6L O2 requirement and w/ CXR
findings concerning for PNA. She was treated with
vanc/cefepime/azithro and narrowed to cefepime/azithro.
Transitioned to levofloxacin by time of discharge for a 7 day
course. She responded well with antibiotics. Had 2 days of
diarrhea which resolved with temporarily withholding antibiotics
with decreased stool output. She was hypotensive on arrival to
the ED, got one dose of stress dose steroids, was transferred to
the FICU where she never required pressors. She was
hemodynamically stable upon discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Language difficulties and headache, found to have left parietal
intraparenchymal hemorrhage
Major Surgical or Invasive Procedure:
___ Three-vessel cerebral angiogram
History of Present Illness:
___ is a ___ right handed woman with a history of
breast
cancer (s/p mastectomy in ___, undergoing XRT), Afib on
Coumadin, CAD on ASA/plavix, and HTN who presented to the ED
with
language difficulties and headache, found to have left parietal
intraparenchymal hemorrhage (IPH) on head CT.
She has had "memory problems" since her surgery in ___,
described as word finding difficulty and not answering questions
appropriately. She had a non-contrast head CT in ___ for workup
of this at ___, which showed small vessel disease but was
otherwise unremarkable.
She began having headaches began 6 weeks ago. She does not get
headaches at baseline. These stopped for a couple weeks but then
returned last week. The HA has been severe and is described as
pounding all over. She has taken Tylenol which helps a ___.
She has decreased appetite with the HA. She has difficulty
describing details but does say sometimes the HA wakes her up
from sleep. She had an MRI with and without contrast ___ at ___ to work up the headache which revealed
leptomeningeal/sulcal FLAIR hyperintensity in the posterior left
parietal lobe and anterolateral left occipital lobe. This was
felt more likely to be collaterals related to left MCA or PCA
stenosis as opposed to leptomeningeal metastatic disease given
lack of significant enhancement. There were no masses seen. Of
note, she called her doctor ___ endorsing waking from sleep at
6am with a ___ headache.
This morning, she continued to have a headache and had worsening
of her speech. She wasn't speaking well and couldn't hold a
conversation. A friend came to visit and was having trouble
understanding her. Her speech was "jumbled" - she rambled
nonsensically on different subjects but was able to say the most
important words. The words were understandable but the
conversation didn't make much sense. Currently per the family,
her speech is back at her baseline.
Of note, her INR was elevated to 3.4 on ___ and has
been running high recently.
In the ED, head CT revealed a 1.9 cm left parietal IPH with
surrounding edema concerning for hemorrhagic mass. Neurosurgery
was consulted to recommended no urgent neurosurgical
intervention. Her INR was elevated to 2.8 and she received
Kcentra and 10mg IV vitamin K. Blood pressure was elevated to
214/102 and she was started on a nicardipine drip for goal
SBP<160 per neurosurgery recommendations. She was given one dose
of Keppra for sz prophylaxis. Neurology was consulted for
further
management.
Review of Systems:
Difficult to obtain ___ speech problems. Endorses some problems
seeing intermittently. Endorses dizziness, weakness in legs
while
walking. Denies dysphagia, Endorses numbness in feet. Endorses
difficulty with gait. No bowel or bladder problems. Denies
recent
fever or chills. Endorses recent weight loss. Denies cough,
shortness of breath. Endorses hoarse voice.
Past Medical History:
Past Medical and Surgical History:
- CKD stage 3
- CAD,Hx of MI
- HTN
- Hypercholesterolemia
- gout
- colonic adenoma
- breast cancer, s/p partial mastectomy. Undergoing XRT
- afib, on Coumadin
- glucose intolerance
- chronic sCHF, EF 45%
Social History:
___
Family History:
- sister died recently of ICH
- HTN in the family
Physical Exam:
Admission Exam ___
EXAMINATION
Vitals: 96.7 74 186/136 18 98%
General: Awake, cooperative, NAD.
HEENT: NC/AT
Neck: Supple.
Pulmonary: clear to auscultation bilaterally
Cardiac: RRR, no murmurs
Abdomen: soft, nondistended
Extremities: no edema, warm
Skin: no rashes or lesions noted.
NEUROLOGIC EXAMINATION
-Mental Status: Awake and alert. Has difficulty relating
history.
Language is fluent but with semantic and phonemic paraphasic
errors. She is perseverative and does not answer most questions
appropriately. She cannot name hammock, cactus, nor feather on
the stroke cards. She has difficulty describing the cookie jar
picture but does describe things on both the left and right.
Reading is intact to phrases on stroke card. She makes mistakes
with repeating of phrases. She has difficult following the
commands of the examination but can follow simple midline and
appendicular commands. Speech was not dysarthric.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 2.5 to 2mm bilaterally. Cannot comply with
confrontation testing of visual fields, but appears to blink to
threat less on the right. Unable to cooperate with funduscopic
exam.
III, IV, VI: EOMI without nystagmus.
V: Facial sensation intact to light touch in all distributions
VII: No facial droop with symmetric upper and lower facial
musculature bilaterally
VIII: Hearing intact to voice.
X: Voice is mildly hoarse.
XI: cannot comply with strength testing of trapezii and SCM
XII: Tongue protrudes in midline
-Motor: She is full strength in deltoids and triceps bilaterally
but is otherwise unable to cooperate with formal testing. She
has
pronation of the right hand. No tremor noted. Legs are
antigravity and she moves them symmetrically.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
- Toes were equivocal bilaterally.
-Sensory: Endorses no deficits to light touch or pinprick
throughout.
-Coordination: patient unable to cooperate with this exam
-Gait: deferred given mental status and HTN
Discharge Exam ___
Pertinent Results:
-------
-------
Imaging
-------
-------
___ CT Head w/o contrast
1. 1.9 cm intraparenchymal hemorrhage with surrounding edema
within the left parietal lobe with associated effacement of
adjacent sulci is worrisome for a hemorrhagic metastatic lesion.
No evidence of herniation.
2. Chronic changes including age-related cortical volume loss
and sequelae of chronic small vessel ischemic disease.
3. 0.3 cm hypodensity within left putamen may represent chronic
lacune or
prominent Virchow ___ space.
4. Empty sella.
___ CTA HEAD W&W/O C & RECO
1. Stable 1.8 cm intraparenchymal left parietal hemorrhage with
surrounding edema and mass effect causing effacement of the
sulci. Underlying intracranial metastasis or mass lesion is not
excluded. Recommend clinical correlation and attention on
followup imaging to resolution.
2. Unremarkable CTA and CTV of the brain with no evidence of
vascular
malformation.
___ MR HEAD W & W/O CONTRAS
1. Study is markedly motion degraded limiting the evaluation.
2. Redemonstration of approximately 1.7 x 1.5 cm left temporal
area of acute hemorrhage. Within limits of examination, lesions
is not clearly demonstrate enhancement. Recommend followup
imaging to resolution to exclude underlying mass obscured by
hemorrhage.
3. Additional punctate areas of hemorrhage in right temporal
lobe, raising concern for possible amyloid angiopathy.
Recommend clinical correlation.
___ CAROTID/CEREBRAL BILAT BILAT
Right PCOMM infundibulum/small aneurysm
M3/M4 branch irregularities and beading of the vessels possibly
consistent with local reversible cerebral vascular constriction
syndrome
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
3. Clopidogrel 75 mg PO DAILY
4. Lisinopril 40 mg PO DAILY
5. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
6. Oxybutynin 15 mg PO DAILY
7. Vitamin D ___ UNIT PO DAILY
8. Warfarin 1 mg PO DAILY16
9. Hydrochlorothiazide 25 mg PO DAILY
10. Anastrozole 1 mg PO DAILY
11. Torsemide 10 mg PO DAILY
12. Gabapentin 100 mg PO BID
13. Sertraline 50 mg PO DAILY
14. meTOPROLOL succinate 25 mg oral DAILY
Discharge Medications:
1. Atorvastatin 20 mg PO QPM
2. Torsemide 5 mg PO DAILY
3. Lisinopril 40 mg PO DAILY
4. Amlodipine 10 mg PO DAILY
5. Verapamil SR 240 mg PO Q24H
6. Anastrozole 1 mg PO DAILY
7. Gabapentin 100 mg PO BID
8. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
9. Oxybutynin 15 mg PO DAILY
10. Sertraline 50 mg PO DAILY
11. Vitamin D ___ UNIT PO DAILY
12. Aspirin 81 mg PO DAILY
13. Clopidogrel 75 mg PO DAILY
14. Carvedilol 3.125 mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
L parietal IPH with SAH secondary to ___
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: History: ___ with question of delirium
TECHNIQUE: Upright AP view of the chest
COMPARISON: None.
FINDINGS:
Severe enlargement of the cardiac silhouette is demonstrated. The aorta is
tortuous and potentially dilated. Mediastinal and hilar contours are
otherwise unremarkable. Pulmonary vasculature is not engorged. Minimal
streaky opacities in the lung bases likely reflect areas of atelectasis. No
focal consolidation, pleural effusion or pneumothorax is visualized. Multiple
clips are seen projecting over the right axillary region. There are no acute
osseous abnormalities.
IMPRESSION:
Severe cardiomegaly. Bibasilar streaky atelectasis without focal
consolidation.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ with breast cancer with severe headache.
TECHNIQUE: Contiguous multidetector CT scan through the head was performed
without intravenous contrast. Axial images displayed as separate 5 mm soft
tissue and 2.5 mm bone algorithm image series
DOSE: This study involved 3 CT acquisition phases with dose indices as
follows:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Sequenced Acquisition 8.0 s, 16.1 cm; CTDIvol = 55.5 mGy (Head) DLP =
891.9 mGy-cm.
Total DLP (Head) = 892 mGy-cm.
COMPARISON: None.
FINDINGS:
A 1.9 x 1.9 cm (02:14) area of intraparenchymal hemorrhage with surrounding
edema is seen within the left parietal lobe with associated effacement of
adjacent sulci. No significant mass effect on the left lateral ventricle.
There is no evidence of large territorial infarction. Mild prominence of
ventricles and sulci is consistent age-related cortical volume loss.
Periventricular, subcortical, and deep white matter hypodensities are likely
sequelae of chronic small vessel ischemic disease. 0.3 cm hypodensity within
the left putamen may represent a chronic lacune or prominent Virchow ___
space. There is an empty sella incidentally noted.
No fracture identified. Bilateral mastoid air cells are partially opacified.
The visualized portion of the paranasal sinuses and middle ear cavities are
clear. The visualized portion of the orbits are unremarkable. Atherosclerotic
calcifications of bilateral cavernous portions of internal carotid arteries
are noted.
IMPRESSION:
1. 1.9 cm intraparenchymal hemorrhage with surrounding edema within the left
parietal lobe with associated effacement of adjacent sulci is worrisome for a
hemorrhagic metastatic lesion. No evidence of herniation.
2. Chronic changes including age-related cortical volume loss and sequelae of
chronic small vessel ischemic disease.
3. 0.3 cm hypodensity within left putamen may represent chronic lacune or
prominent Virchow ___ space.
4. Empty sella.
RECOMMENDATION(S): Recommend dedicated MR with contrast for further
evaluation.
Radiology Report
EXAMINATION: CTA HEAD WANDW/O C AND RECONS Q1213 CT HEAD
INDICATION: ___ year old female with intraparenchymal hemorrhage. Evaluate
for vascular malformation.
TECHNIQUE: Contiguous MDCT axial images were obtained through the brain
without contrast material. Next, rapid axial imaging was performed through
the brain during the uneventful infusion of 70 mL of Omnipaque intravenous
contrast material. Three-dimensional angiographic volume rendered and
segmented images were then generated on a dedicated workstation. This report
is based on interpretation of all of these images.
DOSE: This study involved 7 CT acquisition phases with dose indices as
follows:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Sequenced Acquisition 16.0 s, 16.0 cm; CTDIvol = 55.8 mGy (Head) DLP =
891.9 mGy-cm.
4) Stationary Acquisition 0.5 s, 0.5 cm; CTDIvol = 5.4 mGy (Head) DLP = 2.7
mGy-cm.
5) Stationary Acquisition 4.5 s, 0.5 cm; CTDIvol = 49.0 mGy (Head) DLP =
24.5 mGy-cm.
6) Spiral Acquisition 2.9 s, 22.4 cm; CTDIvol = 34.7 mGy (Head) DLP = 777.5
mGy-cm.
7) Spiral Acquisition 2.9 s, 22.4 cm; CTDIvol = 34.6 mGy (Head) DLP = 777.0
mGy-cm.
Total DLP (Head) = 2,474 mGy-cm.
COMPARISON: ___ noncontrast head CT.
___ contrast brain MRI.
FINDINGS:
CT HEAD WITHOUT CONTRAST: Again seen is a 1.8 x 1.8 cm intraparenchymal
hemorrhage in the left parietal lobe (see 2:16) with surrounding edema and
minimal surrounding mass effect causing effacement of the overlying sulci.
Underlying intracranial metastasis of massive not completely excluded. No
intraventricular or extra-axial hemorrhage is seen. No midline shift is seen.
There is prominence of the ventricles and sulci suggestive involutional
changes. No new intracranial hemorrhage is seen. There are scattered foci
of periventricular, subcortical and deep white matter hypodensities ;
nonspecific, likely secondary to small vessel ischemic changes. There is
intracranial atherosclerotic calcification. Partially empty sella is
incidentally seen. There is a small mucous retention cyst in the right
maxillary sinus. The visualized paranasal sinuses, mastoid air cells and
middle ear cavities are otherwise clear. The orbits are unremarkable.
CTA HEAD: The vessels of the circle of ___ and their principal intracranial
branches are patent, without high grade stenosis, occlusion,
malformation,aneurysm greater than 3 mm in sizeor other vascular abnormality.
The dural venous sinuses are patent.
CTV head: Patent cerebrovascular venous circulation.
IMPRESSION:
1. Stable 1.8 cm intraparenchymal left parietal hemorrhage with surrounding
edema and mass effect causing effacement of the sulci. Underlying
intracranial metastasis or mass lesion is not excluded. Recommend clinical
correlation and attention on followup imaging to resolution.
2. Unremarkable CTA and CTV of the brain with no evidence of vascular
malformation.
RECOMMENDATION(S): Stable 1.8 cm intraparenchymal left parietal hemorrhage
with surrounding edema and mass effect causing effacement of the sulci.
Underlying intracranial metastasis or mass lesion is not excluded. Recommend
clinical correlation and attention on followup imaging to resolution.
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST T___ MR HEAD
INDICATION: ___ year old female with intraparenchymal hemorrhage . Evaluate
for intracranial mass or amyloid angiopathy.
TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After
administration of 8 mL of Gadavist intravenous contrast, axial imaging was
performed with gradient echo, FLAIR, diffusion, and T1 technique. Sagittal
MPRAGE imaging was performed and re-formatted in axial and coronal
orientations. The examination was performed using a 1.5T MRI.
COMPARISON: ___ contrast head CTA.
___ noncontrast head CT.
FINDINGS:
The study is moderately degraded by motion limiting the evaluation.
There is a 1.7 x 1.5 cm left temporal lobe non enhancing T1 hypointense, T2
hyperintense, nonenhancing lesion with fast diffusion and associated
susceptibility artifact in keeping with a focus of intracranial hemorrhage as
seen on recent prior CT of the head. There is surrounding FLAIR signal
abnormality in keeping with vasogenic edema. There is no associated
underlying enhancement to suggest an intracranial metastasis though evaluation
for the postcontrast images is markedly limited given the motion artifact.
There is suggestion of punctate right temporal areas of susceptibility that do
not clearly correspond to areas of calcification on ___ noncontrast
head CT, raising concern for punctate areas of hemorrhage (see 11:10).
No acute intracranial infarct is seen. No midline shift is seen. The
ventricles and sulci are normal in caliber and configuration.
No osseous abnormalities are seen. There is mild mucosal thickening in
bilateral maxillary sinuses with partial fluid opacification of bilateral
mastoid air cells. The remaining paranasal sinuses and middle ear cavities
are clear. The orbits are unremarkable. The visualized portion of the
principle vascular flow voids are preserved.
IMPRESSION:
1. Study is markedly motion degraded limiting the evaluation.
2. Redemonstration of approximately 1.7 x 1.5 cm left temporal area of acute
hemorrhage. Within limits of examination, lesions is not clearly demonstrate
enhancement. Recommend followup imaging to resolution to exclude underlying
mass obscured by hemorrhage.
3. Additional punctate areas of hemorrhage in right temporal lobe, raising
concern for possible amyloid angiopathy. Recommend clinical correlation.
RECOMMENDATION(S):
1. Redemonstration of approximately 1.7 x 1.5 cm left temporal area of acute
hemorrhage. Within limits of examination, lesions is not clearly demonstrate
enhancement. Recommend followup imaging to resolution to exclude underlying
mass obscured by hemorrhage.
2. Additional punctate areas of hemorrhage in right temporal lobe, raising
concern for possible amyloid angiopathy. Recommend clinical correlation.
Radiology Report
INDICATION: ___ year old woman with concern for reversible cerebrovascular
constriction syndrome.
COMPARISON: None
TECHNIQUE: The patient was transferred from the intensive care unit to the
angio suite and positioned on the angio table. The patient was prepped and
draped in usual fashion and a time-out was performed. Next, the right femoral
artery was localized using anatomic landmarks and the skin superficial was
infiltrated with local anesthetic. A 5 ___ sheath was placed into the
femoral artery an ___ 2 diagnostic catheter was used to select the right
common carotid artery, left common carotid artery, left vertebral artery. AP,
lateral and oblique views of the intracranial circulation were obtained. The
patient tolerated the procedure well the groin was sealed with Angio-Seal and
the patient was transferred back to the intensive care unit.
DEVICES: ___ 2
0.038 hydrophilic wire
PROCEDURE:
1. Three-vessel cerebral angiogram
FINDINGS:
Right common carotid artery: There is significant tortuosity in the common
carotid artery proximally without carotid bifurcation arteriosclerotic disease
or stenosis. The intracranial vasculature is unremarkable with exception of a
slight dilatation in the area of the PCOMM origin which may represent an
infundibulum or small aneurysm.
Left common carotid artery: The distal internal external carotid artery,
anterior cerebral artery and middle cerebral artery of well visualized.
Distally in the middle cerebral artery in the M3/M4 branch territory there is
some caliber irregularities and some beading of the artery.
Left vertebral artery: AP and lateral views of the posterior circulation are
somewhat limited due to motion artifact. There is, however, no gross
abnormality noted.
IMPRESSION:
Right PCOMM infundibulum/small aneurysm
Left M3/M4 branch irregularities and beading of the vessels possibly
consistent with local reversible cerebral vascular constriction syndrome
I, ___, participated in this procedure. I, ___
___, was present for the entirety of this procedure and supervised all
critical steps.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old woman with prior L parietal IPH and SAH and RCVS.
Need to know whether or not to restart home coumadin. // Evaluate interval
changes.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. No reformatted images were produced.
DOSE: This study involved 3 CT acquisition phases with dose indices as
follows: 1) CT Localizer Radiograph 2) CT Localizer Radiograph 3) Sequenced
Acquisition 6.4 s, 16.7 cm; CTDIvol = 53.8 mGy (Head) DLP = 897.1 mGy-cm.
Total DLP (Head) = 897 mGy-cm.
COMPARISON: ___ contrast-enhanced head MRI.
___ noncontrast head CT.
FINDINGS:
Again seen is a 1.9 x 1.7 cm focus of intraparenchymal hemorrhage and
adjacent cytotoxic edema noted within the left temporal lobe (03:15), largely
unchanged from the prior examination due to ___. No additional areas
of intracranial hemorrhage are identified. There is no significant mass
effect or evidence of midline shift. A hypodensity within the left putamen is
unchanged and likely represents a chronic infarct. No large vascular
territorial infarction.
The ventricles and sulci are moderately enlarged, compatible with age related
atrophic changes. Periventricular and subcortical white matter hypodensities
are noted, likely the sequelae of chronic small vessel ischemic disease.
There is preservation of gray-white matter differentiation. The basal cisterns
are patent.
There is no evidence of fracture. The visualized portion of the paranasal
sinuses, mastoid air cells, and middle ear cavities are clear. The visualized
portion of the orbits are unremarkable.
IMPRESSION:
1. Stable appearance of a left temporal intraparenchymal hemorrhage with mild
surrounding vasogenic edema. No evidence for new intracranial hemorrhage or
appreciable local mass effect.
2. Evidence of moderate global cerebral atrophy and sequelae of chronic small
vessel ischemic disease.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old woman with sCHF EF45% // ? pulmonary edema ?
pulmonary edema
IMPRESSION:
In comparison with the study of ___, there is again substantial
enlargement of the cardiac silhouette without vascular congestion or pleural
effusion. This combination raises the possibility of cardiomyopathy, or even
possibly pericardial effusion.
No evidence of acute focal pneumonia.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Headache, Lethargy
Diagnosed with INTRACEREBRAL HEMORRHAGE, HYPERTENSION NOS, HX OF BREAST MALIGNANCY, LONG TERM USE ANTIGOAGULANT
temperature: 96.7
heartrate: 74.0
resprate: 18.0
o2sat: 98.0
sbp: 186.0
dbp: 136.0
level of pain: 8
level of acuity: 2.0 | Ms. ___ is a ___ R handed F with a history of breast cancer
(s/p mastectomy in ___, undergoing XRT), Afib on Warfarin, CAD
on ASA/plavix, and HTN who presented to the ED with language
difficulties and headache and was found to have a left parietal
IPH and SAH. She was initially admitted to the ICU for close
monitoring and blood pressure control by nicardipine drip and
transferred to the floor once she was weaned from the
nicardipine drip to PO medications. Her hospital course was as
follows.
# Left parietal IPH and SAH: A ___ revealed L parietal IPH on
presentation, and a subsequent angiogram was consistent with
RCVS. Ms. ___ was initially admitted to the ICU for tight
blood pressure control (Goal SBP<140) with nicardipine GTT and
her home medications. Given her bleed, her warfarin, ASA, and
plavix were held; and she received a platelet transfusion to
reverse ASA/plavix effects and 5mg IV Vitamin K to reverse her
warfarin. After her angiogram, she was also started on
verapamil. Her ASA/plavix was restarted 1 week after her bleed,
given her history of cardiac stents. She will follow up with Dr.
___ discharge. Hypertension managed as below:
# Hypertension: Ms. ___ has a history of HTN controlled at
home with multiple medications. She was initially maintained on
her home Lisinopril, Metoprolol, HCTZ, and torsemide along with
a nicardipine drip. She was weaned off of the drip. Her blood
pressure remained difficult to control, but she became
normotensive with a new regimen of amlodipine 5 mg, carvedilol
3.125 mg, verapamil 240 mg, lisinopril 40 mg and torsemide 5 mg.
Her HCTZ and metoprolol were stopped ___ to volume status as
well as well controlled heart rates.
#Chronic CHF: Ms. ___ has a history of heart failure,
previous MI, CAD, and cardiac stents. Her ASA and plavix were
held and she received a platelet transfusion in the setting of
her bleed, but she was restarted upon transfer to the floor
given her stents. Her home dose of 80mg QD Lipitor was reduced
to 20mg QD in the setting of her IPH and continued at this dose
upon discharge. She will follow up with her cardiologist to
titrate her Lipitor.
#Afib: Ms. ___ is on ___ at home for her Afib. Given
her bleed, her warfarin was discontinued on admission, and she
received 5mg IV vitamin K. Her INR was maintained <1.5
throughout her stay. She will follow up with her cardiologist
to restart and titrate this medication.
#Right hallux pain: Ms. ___ developed pain in the PIP joint
of her right hallux during her stay that was consistent with
gout. She could not be treated with NSAIDs given her ICH and
___ not receive colchicine given her CAD. She was treated
with tylenol PRN for pain and will follow up with her PCP after
discharge.
#Breast Cancer: Ms. ___ is to begin radiation oncology
treatments on ___ - ___.
#Transitional Issues:
- REversible Cerebral Vasoconstriction Syndrome:
1. Follow up with Dr. ___
2. Continue Verapamil until follow up with Dr. ___
3. Tentative plan for repeat vessel imaging. Date TBD by Dr.
___
- ___:
1. RCVS workup as above.
2. Strict BP control. Goal: Normotension
3. Okay to continue ASA and plavix. Would not resume coumadin
and would not recommend dual antiplatelet with coumadin in the
future. However, could consider single antiplatelet with
apixaban if patient has sustained atrial fibrillation.
- HTN
1. Transition from metoprolol to verapamil given RCVS
2. Appear volume down, so Torsemide decreased and d/c-ed HCTZ
3. Please titrate lisinopril, amlodipine, carvedilol as needed.
- Breast Cancer
1. Radiation oncology treatments on ___ - ___. Next
appointment is 8:30 am on ___ at ___.
- Gout
1. Follow for symptoms. Would not recommend NSAIDs (due to dual
antiplatelet and recent bleed) or prednisone (due to blood
pressure) |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with h/o HLD presenting with 2 weeks of fevers, night
sweats, dry cough and new onset of crampy, right-sided
non-radiating abdominal pain. He reports on ___, two weeks
ago. While sitting on the couch watching TV a "wave of coldness"
hit him with chills and sweats that lasted for about half an
hour. Since then he's had intermittent, sudden-onset bouts of
sweats/chills with fever to 102.6 F. He also reports fatigue,
aching muscles and joints diffusely.
He has had no weight loss, but endorses loss of appetite. He has
had some nausea but no vomiting. He has had intermittent loose,
nonbloody stools and less urination than normal. No chest pain
or shortness of breath. Does have cough that has worsened over
past month. He has had off and on headaches that worsen when he
coughs or sneezes, improve with Tylenol/ibuprofen. Feels a
"clicking" in his neck but no specific stiffness. No visual or
hearing changes, no photophobia. No rashes or known tick bites
although patient is a ___ and reports many insect bites. No
sick contacts or family members. No recent travel.
His initial vitals in the ED were 99.0 F, HR 91, BP 120/80, RR
18, O2 sat 99%RA. Tmax was 100.6. Labs were notable for ALT 378,
AST 252, AP 370, CRP 76.1, WBC 5.4, H/H 14.7/43.0, PLT 84,
normal chemistry, normal lactate, unremarkable UA, and negative
parasite smear. Lyme serologies were sent. Blood and urine
cultures were drawn. Chest x-ray showed "No acute
cardiopulmonary process." He received acetaminophen 650mg PO,
ketorolac 30mg IV, 1L NS IVF, and doxycycline 100mg PO.
Past Medical History:
HLD
Social History:
___
Family History:
Father: HLD
Mother: h/o knee replacements x2
Physical Exam:
On admission:
Vital Signs: 98.4 F, BP 120/63, HR 72. RR 18, O2 sat 98% RA
General: Alert, oriented, conversant, lying in bed looking up at
the ceiling
HEENT: Sclera anicteric, MMM, oropharynx clear, neck supple, JVP
not elevated, no LAD
CV: RRR, no murmurs appreciated
Lungs: CTAB
Abdomen: Diffusely TTP, bloated-appearing and tympanitic to
percussion, no HSM appreciated
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: EOMI, PERRL, symmetric face, facial muscles intact,
strength ___
MSK: no muscle tenderness or joint pain to palpation. Joints
appear non-erythematous, non-swollen
On discharge:
Vitals: T: 99.2 F (max overnight) BP: 102/59 P: 66 R: 18 O2:
100% RA
General: Alert, oriented, fatigued, lying in bed
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: RRR, no murmurs appreciated
Abdomen: soft, NTND bowel sounds present, no rebound tenderness
or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: no rashes appreciated
Neuro: EOMI, PERRL, moving all four limbs equally
Pertinent Results:
___ 06:50AM BLOOD WBC-5.3 RBC-3.54* Hgb-13.1* Hct-37.1*
MCV-105* MCH-37.0* MCHC-35.3 RDW-15.2 RDWSD-59.3* Plt Ct-84*
___ 01:10PM BLOOD WBC-5.4 RBC-4.06* Hgb-14.7 Hct-43.0
MCV-106* MCH-36.2* MCHC-34.2 RDW-15.2 RDWSD-59.7* Plt Ct-84*
___ 01:10PM BLOOD Neuts-70.1 ___ Monos-8.4 Eos-0.2*
Baso-0.4 Im ___ AbsNeut-3.74 AbsLymp-1.08* AbsMono-0.45
AbsEos-0.01* AbsBaso-0.02
___ 06:50AM BLOOD Plt Ct-84*
___ 06:50AM BLOOD ___ PTT-28.4 ___
___ 01:10PM BLOOD Plt Ct-84*
___ 06:50AM BLOOD ___
___ 06:50AM BLOOD ___
___ 01:10PM BLOOD Parst S-NEGATIVE
___ 01:10PM BLOOD Ret Aut-2.7* Abs Ret-0.11*
___ 06:50AM BLOOD Glucose-102* UreaN-11 Creat-1.0 Na-139
K-3.9 Cl-102 HCO3-25 AnGap-16
___ 01:10PM BLOOD Glucose-96 UreaN-9 Creat-1.2 Na-136 K-3.9
Cl-99 HCO3-25 AnGap-16
___ 01:10PM BLOOD estGFR-Using this
___ 06:50AM BLOOD ALT-254* AST-130* LD(LDH)-266*
AlkPhos-298* TotBili-0.7
___ 01:10PM BLOOD ALT-378* AST-252* LD(LDH)-360* CK(CPK)-60
AlkPhos-370* TotBili-1.0
___ 06:50AM BLOOD Calcium-9.0 Phos-3.0 Mg-2.0
___ 01:10PM BLOOD Albumin-4.0
___ 06:50AM BLOOD HBsAg-PND HBsAb-PND HBcAb-PND HAV Ab-PND
___ 06:50AM BLOOD CRP-56.6*
___ 01:10PM BLOOD CRP-76.1*
___ 06:50AM BLOOD HCV Ab-PND
___ 02:07PM BLOOD Lactate-1.1
___ 06:00PM BLOOD ANAPLASMA PHAGOCYTOPHILUM (HUMAN
GRANULOCYTIC EHRLICHIA AGENT) IGG/IGM-PND
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 20 mg PO QPM
2. Cialis (tadalafil) 10 mg oral Other
Discharge Disposition:
Home
Discharge Diagnosis:
Final diagnosis: Fever
Secondary diagnosis: HTN
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ male with fever and cough. Evaluate for acute
infectious process
TECHNIQUE: Frontal and lateral chest radiographs were obtained with the
patient in the upright position.
COMPARISON: None.
FINDINGS:
The lungs are clear of focal consolidation, pleural effusion or pneumothorax.
The heart size is normal. The mediastinal contours are normal.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ year old man with new transaminitis, thrombocytopenia and
fevers. Evaluate for etiology of transaminitis.
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: None.
FINDINGS:
LIVER: The liver is diffusely echogenic compatible with fatty infiltration.
The contour of the liver is smooth. There is no focal liver mass. The main
portal vein is patent with hepatopetal flow. There is no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. The CBD measures 5 mm.
GALLBLADDER: There is no evidence of stones or gallbladder wall thickening.
PANCREAS: The pancreas was not well seen secondary to overlying bowel gas.
KIDNEYS: Survey views of the right kidney does not demonstrate any masses,
hydronephrosis, or stones.
RETROPERITONEUM: Visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
Echogenic liver consistent with steatosis. Other forms of liver disease
including hepatic fibrosis or cirrhosis or steatohepatitis cannot be excluded
on the basis of this examination.
Gender: M
Race: OTHER
Arrive by WALK IN
Chief complaint: Fever, Cough
Diagnosed with FEVER, UNSPECIFIED
temperature: 99.0
heartrate: 91.0
resprate: 18.0
o2sat: 99.0
sbp: 120.0
dbp: 80.0
level of pain: 6
level of acuity: 3.0 | Mr. ___ is a ___ yo male with h/o HLD, otherwise healthy,
presenting with episodic fevers to 102.1 F, chills, sweats, and
malaise for the past two weeks.
ACTIVE ISSUES:
- Fever:
He was monitored in the hospital for episodes of fever. He
reported two episode of subjective fever during his first night
here but these temperatures were not recorded. His Tmax here was
99.2 F. He received an extensive diagnostic workup including
blood cultures, HIV, CMV, EBV serologies, LDH, Lyme serologies,
Anaplasma, parasite smears x3, CRP and CPK. Of those results, a
Lyme serology was positive on ___ and confirmatory Western
blot testing is pending. His parasite smears x3 were negative.
His HIV antibody test was negative.
- Transaminitis:
His LFTs were trended daily and downtrended to WNL. He received
a RUQ u/s on ___ that demonstrated steatosis and no acute
changes to explain the pt's sx.
- Thrombocytopenia:
His CBC was trended daily and on day of discharge he had a
platelet count of 88.
CHRONIC ISSUES:
- HLD: he was continued on his home regimen of 20 mg
atorvastatin for day of admission; this was discontinued on day
2 for concern in light of elevated LFTs.
TRANSITIONAL ISSUES:
- Workup for fever: he has labwork pending, including blood
cultures, CMV, EBV serologies, LDH, Lyme serologies, and
Anaplasma. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
aspirin / ibuprofen
Attending: ___.
Chief Complaint:
Found down
Major Surgical or Invasive Procedure:
arterial line x 2
PICC ___
History of Present Illness:
Ms. ___ is ___ year old female with PMH
HTN, HLD, stroke, and OSA who was found down by her family at
10:45am this morning of unclear etiology s/p intubation for
airway protection now transferred to MICU for further
management.
Per the patient's family, the patient was ___ her normal state of
health until a couple of days ago when she was a little more
somnolent and "out of it" with intermittent episodes of
"incoherent speech." No focal deficits noted and the patient was
not complaining of any fevers, chills, n/v, CP, SOB, diarrhea or
urinary symptoms. This morning, her friend was visiting her and
per the family, stated that the patient looked overall
unwell/sickly. The friend called EMS given that the patient
looked ill and following the phone call, the patient reportedly
fell to the ground and began "convulsing." By the time EMS
arrived, the convulsions had stopped and the patient was
unresponsive.
Per EMS evaluation, the patient was unresponsive with pinpoint
pupils and SpO2 50%. She was bagged without difficulty and her
O2 sats improved. She was given narcan without improvement and
brought into ___ ED. Once ___ the ED, the patient was again bag
ventilated without difficulty but was intubated for airway
protection.
Upon arrival to the ED, initial vitals:
100.2 83 ___ Intubation
Labs notable for:
WBC 14.5 HgB 12.6 Plt 391
Na:142 K:4.6 Cl:109 TCO2:15 BUN 14 Cr 0.7 Glu:244
___: 11.4 PTT: 28.7 INR: 1.1
Lactate:11.4, Fibrinogen 422
Utox: Negative Stox: Negative
UA: Neg for leuks, neg for nitrites, >600 protein, 1000 glucose,
trace ketones, no bacteria
Imaging notable for:
CXR showed appropriate ET tube placement. Low lung volumes with
basilar atelectasis as well as streaky opacity ___ left lung base
c/f aspiration
Non-con head CT: no evidence of acute bleed or infarction. Has
hypodensity ___ the right centrum semiovale extending into basal
ganglia compatible with chronic infarct
CTA Head and Neck: Read pending
Neurology was consulted given concern for stroke and recommended
MRI head, empiric treatment for HSV and bacterial meningitis as
well as LP.
An LP was performed and the patient was given:
-Acyclovir 550 mg IV ONCE
-CefePIME 2 g IV ONCE
-Vancomycin 1000 mg IV ONCE
-NiCARdipine 0.5-3 mcg/kg/min IV DRIP TITRATE TO Goal BP<180
Upon arrival to the MICU, the patient had an episode of full
body convulsions. She was given Ativan 2mg IV x1 with
improvement of symptoms.
Past Medical History:
HLD
HTN
Stroke ___ with left sided facial droop and left arm weakness
with imaging at that time showing infarct ___ the right corona
radiata extending to the superior portion of the right basal
ganglia region
NIDDM
OSA
Known thyroid nodule
Primary hyperparathyroidism
Social History:
___
Family History:
-Mother: DM, HTN, stroke at age ___ no seizures or migraines
-Father: ___
Physical ___:
ADMISSION PHYSICAL EXAM:
=========================
VITALS: 99.4 144/72 80 30 100% on 350/26 PEEP 5 FiO2 50%
GENERAL: Intubated, sedated, not following commands
HEENT: ET tube ___ place, dry MM, pinpoint pupils that are
minimally reactive to light
LUNGS: Clear to auscultation bilaterally on anterior lung exam
CV: Regular rate and rhythm, no murmurs
ABD: soft, non-tender, +BS
EXT: Warm, well perfused, no edema
NEURO: Sedated, not withdrawing to pain or following commands
DISCHARGE EXAM:
=========================
VS - 98.7PO 155/56 hr51 18 96 RA
General: well appearing, NAD ___ bed, CPAP on
HEENT: sclera anicteric, MMM,
Neck: No JVD, visible carotid upstroke
CV: RRR, III/VI systolic murmur
Lungs: CTAB, no r/m/g
Abdomen: BS present, soft NTND
GU: deferred
Ext: WWP, no calf tenderness, DP 2+
Neuro: CNII-XII intact, ___ throughout, sensation intact
throughout
Skin: no rash
Pertinent Results:
ADMISSION LABS:
==============
___ 11:20AM BLOOD ___ PTT-28.7 ___
___ 07:16PM BLOOD Glucose-127* UreaN-13 Creat-0.8 Na-142
K-3.0* Cl-107 HCO3-24 AnGap-14
___ 07:16PM BLOOD ALT-21 AST-81* LD(LDH)-292* AlkPhos-79
TotBili-0.3
___ 03:39AM BLOOD proBNP-360*
___ 07:16PM BLOOD Calcium-10.9* Phos-2.3* Mg-1.3*
___ 04:06AM BLOOD %HbA1c-6.5* eAG-140*
___ 11:20AM BLOOD Lipase-39
___ 11:20AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
IMAGING:
========
___ EEG: This is an abnormal continuous ICU monitoring study
because of 1) occasional runs of bifrontal blunted sharp waves
with a triphasic morphology, consistent with bifrontal cortical
irritability that may be toxic-metabolic ___ etiology. (2)
Discontinuous and diffusely slow background, indicative of a
moderate to severe etiologically-nonspecific encephalopathy or
due to medication effects. The excessive beta activity can be
due to medication effects. There is one pushbutton activation
for tremulous body movement, without EEG correlate. There are no
electrographic seizures.
___ CTA HEAD/NECK
1. No evidence of acute intracranial abnormality.
2. The vessels of the circle of ___ and their major
intracranial branches are patent without stenosis, occlusion, or
aneurysm formation.
3. The carotid and vertebral arteries and their major branches
are patent
without evidence of significant stenosis or occlusion.
4. 1.4 x 1.9 cm heterogeneous left thyroid lobe lesion is
incompletely
evaluated on this exam. Recommend dedicated thyroid ultrasound
for further evaluation.
5. Paranasal sinus disease, as described above.
___ MRI HEAD W/O CONTRAST
1. Right parietal lobe subacute infarction.
2. No evidence of acute infarction, hemorrhage or mass.
3. Right basal ganglia chronic lacunar infarction.
4. Enlargement of bilateral pterygoid muscles with corresponding
enhancement, which is new from ___ and increased from ___.
Given the absence of fatty infiltration on CT, finding is felt
most likely to be related to myositis, perhaps related to a
seizure.
___ TTE
The left atrium is elongated. No atrial septal defect is seen on
color flow Doppler, but there is early appearance of agitated
saline/microbubbles ___ the left atrium/ventricle at rest most
consistent with an atrial septal defect or stretched patent
foramen ovale (though a very proximal intrapulmonary shunt
cannot be fully excluded). There is moderate symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Left ventricular systolic function is hyperdynamic (EF =
75%). Tissue Doppler imaging suggests an increased left
ventricular filling pressure (PCWP>18mmHg). Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis or aortic regurgitation. There
is no aortic valve stenosis. The mitral valve leaflets are
mildly thickened. The estimated pulmonary artery systolic
pressure is normal. There is no pericardial effusion. There is
an anterior space which most likely represents a prominent fat
pad.
IMPRESSION: ASD/PFO detected on resting bubble study
___ RENAL ARTERY ULTRASOUND
1. Suboptimal right renal arterial waveforms, although without
overt tardus parvus morphology. Overall diastolic flow on the
right appears decreased, although unclear whether this is
technical ___ nature. If clinically needed, consider either CTA
or MRA for better assessment of renal arterial supply.
2. Left renal arterial waveforms are within normal limits.
3. Unremarkable morphologic appearance of the bilateral
kidneys. Left renal cyst.
___ CXR
NG tube tip is ___ the stomach. ET tube is ___ standard position.
The cuff
appears mildly hyperinflated. Cardiac size cannot be evaluated.
There are low lung volumes. Pulmonary arteries are enlarged
consistent with pulmonary hypertension. There is mild
interstitial edema. Bibasilar opacities are consistent with
atelectasis increased from prior.
___ CT ABD/PEL C+
1. Mild fat stranding about the duodenum, may reflect
duodenitis.
2. Homogeneously enhancing 1.6 x 1.5 cm left adrenal nodule is
indeterminate,
but statistically likely an adenoma. If further
characterization is desired,
a dedicated adrenal protocol CT or MRI could be obtained.
3. Diverticulosis.
4. CT chest dictated separately.
___ CT CHEST C+
1. Predominantly right upper lobe alveolar abnormality is
unlikely to be
asymmetric pulmonary edema, more likely infection and/or
hemorrhage.
2. Bibasilar consolidation, left greater than right, likely
atelectasis.
3. Small, bilateral layering, nonhemorrhagic pleural effusions.
4. Moderately severe, compression fracture of the T10 vertebral
body is age indeterminate.
5. Pulmonary artery enlargement is suggestive of although not
diagnostic for pulmonary hypertension.
___ MRI/MRA RENAL, ABDOMEN/PELVIS
1. 1.8 cm left adrenal nodule is consistent with an adrenal
adenoma.
2. No evidence of renal artery stenosis.
3. Hepatic steatosis.
4. Thickening and edema of the duodenum is consistent with
duodenitis.
MICROBIOLOGY:
=============
___ BLOOD CX: negative
___ URINE CX: negative
___ CSF CX: negative. Gram stain: negative. HSV PCR:
negative.
___ SPUTUM CX:
GRAM STAIN (Final ___:
>25 PMNs and <10 epithelial cells/100X field.
2+ ___ per 1000X FIELD): GRAM NEGATIVE ROD(S).
2+ ___ per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND SINGLY.
RESPIRATORY CULTURE (Final ___:
Commensal Respiratory Flora Absent.
Due to mixed bacterial types ( >= 3 colony types) an
abbreviated
workup will be performed appropriate to the isolates
recovered from
this site.
CHRYSEOBACTERIUM INDOLOGENES. SPARSE GROWTH.
STENOTROPHOMONAS MALTOPHILIA. SPARSE GROWTH.
STAPH AUREUS COAG +. SPARSE GROWTH.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ 1 S
DISCHARGE LABS
___ 02:00PM BLOOD WBC-9.1 RBC-2.62* Hgb-7.9* Hct-24.3*
MCV-93 MCH-30.2 MCHC-32.5 RDW-15.0 RDWSD-50.0* Plt ___
___ 02:00PM BLOOD Plt ___
___ 07:00AM BLOOD Glucose-98 UreaN-12 Creat-0.8 Na-140
K-3.7 Cl-100 HCO3-23 AnGap-21*
___ 08:10AM BLOOD CK-MB-<1 cTropnT-<0.01
___ 12:00PM BLOOD ALT-7 AST-15 LD(LDH)-280* AlkPhos-55
TotBili-0.2
___ 07:00AM BLOOD Albumin-3.4* Calcium-11.3* Mg-1.7
___ 05:39AM BLOOD calTIBC-252* VitB12-623 Folate-11
Ferritn-100 TRF-194*
___ 04:06AM BLOOD %HbA1c-6.5* eAG-140*
___ 05:39AM BLOOD TSH-3.0
___ 08:52AM BLOOD PTH-117*
___ 03:19AM BLOOD 25VitD-31
___ 12:00PM BLOOD PEP-NO SPECIFI IgG-947 IgA-201 IgM-23*
IFE-NO MONOCLO
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. mometasone furoate (bulk) 100 % INH DAILY
2. Loratadine 10 mg PO DAILY
3. Jardiance (empagliflozin) 10 mg oral DAILY
4. Lisinopril 80 mg PO DAILY
5. Venlafaxine 37.5 mg PO BID
6. Labetalol 200 mg PO BID
7. Alendronate Sodium 70 mg PO QMON
8. Gabapentin 300 mg PO QHS
9. Clonidine Patch 0.3 mg/24 hr 1 PTCH TD QMON
10. Omeprazole 40 mg PO BID
11. glimepiride 0.5 mg oral DAILY:PRN bs > 150
12. amLODIPine 10 mg PO HS
13. MetFORMIN XR (Glucophage XR) 1000 mg PO BID
14. Atorvastatin 20 mg PO QPM
15. Gemfibrozil 600 mg PO BID
16. Vitamin D 6000 UNIT PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Cinacalcet 30 mg PO BID
3. HydrALAZINE 100 mg PO Q8H
4. Isosorbide Dinitrate ER 40 mg PO BID
5. Rivaroxaban 15 mg PO BID Duration: 21 Days
6. Spironolactone 200 mg PO DAILY
7. Labetalol 200 mg PO TID
8. Lisinopril 40 mg PO QHS
9. Alendronate Sodium 70 mg PO QMON
10. amLODIPine 10 mg PO HS
11. amLODIPine 10 mg PO HS
12. Atorvastatin 20 mg PO QPM
13. Gabapentin 300 mg PO QHS
14. Gemfibrozil 600 mg PO BID
15. glimepiride 0.5 mg oral DAILY:PRN bs > 150
16. Jardiance (empagliflozin) 10 mg oral DAILY
17. Loratadine 10 mg PO DAILY
18. MetFORMIN XR (Glucophage XR) 1000 mg PO BID
19. mometasone furoate (bulk) 100 % INH DAILY
20. Omeprazole 40 mg PO BID
21. Venlafaxine 37.5 mg PO BID
22. Vitamin D 6000 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnoses:
Primary hyperparathyroidism
Seizure
Hypertensive emergency
___
Pneumonia
DVT
Secondary diagnoses:
Anemia
GERD
Diabetes
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
INDICATION: History: ___ with s/p intubation // Confirm ETT
TECHNIQUE: Portable upright chest radiograph
COMPARISON: None
FINDINGS:
The endotracheal tube terminates approximately 3.7 cm above the carina. The
enteric tube courses beyond the diaphragm, terminating in the left upper
quadrant. Lung volumes are low with bibasilar atelectasis. More confluent
streaky opacity at the left lung base may represent sequelae of aspiration.
Heart size is likely accentuated by the portable technique. No pneumothorax
or large pleural effusion.
IMPRESSION:
1. Appropriate positioning of endotracheal and enteric tubes.
2. Low lung volumes with bibasilar atelectasis. More confluent streaky
opacity at the left lung base could be due to aspiration.
Radiology Report
EXAMINATION: 5 Q16 CT NECK
INDICATION: History: ___ with sudden unreresponsiveness // ?bleed
TECHNIQUE: Contiguous MDCT axial images were obtained through the brain
without contrast material. Subsequently, helically acquired rapid axial
imaging was performed from the aortic arch through the brain during the
infusion of 70 mL of Omnipaque intravenous contrast material.
Three-dimensional angiographic volume rendered, curved reformatted and
segmented images were generated on a dedicated workstation. This report is
based on interpretation of all of these images.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 6.4 s, 16.0 cm; CTDIvol = 56.1 mGy (Head) DLP =
897.1 mGy-cm.
2) Stationary Acquisition 7.5 s, 0.5 cm; CTDIvol = 81.7 mGy (Head) DLP =
40.8 mGy-cm.
3) Spiral Acquisition 4.8 s, 37.9 cm; CTDIvol = 31.8 mGy (Head) DLP =
1,207.9 mGy-cm.
Total DLP (Head) = 2,146 mGy-cm.
COMPARISON: CT head without contrast from ___
FINDINGS:
CT HEAD WITHOUT CONTRAST:
There is no intracranial hemorrhage or evidence of acute infarction on this
noncontrast CT. There is a hypodensity in the right centrum semiovale
extending into the basal ganglia, compatible with a chronic infarct.
Ventricles and sulci are normal in size and configuration.
Mild mucosal thickening is seen in the bilateral ethmoid air cells.
Aerosolized secretions, mild-to-moderate mucosal thickening, and a mucous
retention cyst right noted in the left maxillary sinus. Otherwise, the
remaining visualized portion of the paranasal sinuses, mastoid air cells, and
middle ear cavities are clear. The visualized portion of the orbits are
unremarkable.
CTA HEAD:
The vessels of the circle of ___ and their principal intracranial branches
appear normal without stenosis, occlusion, or aneurysm formation. The dural
venous sinuses are patent.
CTA NECK:
There is a dominant right vertebral artery. The carotid and vertebral
arteries and their major branches appear normal with no evidence of stenosis
or occlusion. There is no evidence of internal carotid stenosis by NASCET
criteria.
An enteric tube is partially visualized in the esophagus. An ETT terminates
in the distal trachea. A 1.4 x 1.9 cm heterogeneous lesion is noted in the
left thyroid lobe (series 5: Image 75). Atelectasis is noted in the bilateral
dependent lung apices. Atherosclerotic calcifications are seen in the aortic
arch, right vertebral artery origin, and bilateral carotid bifurcations.
IMPRESSION:
1. No evidence of acute intracranial abnormality.
2. The vessels of the circle of ___ and their major intracranial branches
are patent without stenosis, occlusion, or aneurysm formation.
3. The carotid and vertebral arteries and their major branches are patent
without evidence of significant stenosis or occlusion.
4. 1.4 x 1.9 cm heterogeneous left thyroid lobe lesion is incompletely
evaluated on this exam. Recommend dedicated thyroid ultrasound for further
evaluation .
5. Paranasal sinus disease, as described above.
RECOMMENDATION(S): Recommend dedicated thyroid ultrasound for further
evaluation.
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST T___ MR HEAD
INDICATION: ___ patient with hypertension, prior stroke, found down
at home. Concern for stroke versus encephalitis.
TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After
administration of 8 mL of Gadavist intravenous contrast, axial imaging was
performed with gradient echo, FLAIR, diffusion, and T1 technique. Sagittal
MPRAGE imaging was performed and re-formatted in axial and coronal
orientations.
COMPARISON: MRI and MRA brain ___, CTA head and neck ___, CT head ___
FINDINGS:
There is no evidence of acute infarction or hemorrhage. There is right
lentiform nucleus and caudate chronic lacunar infarction with mild ex vacuo
dilatation of the right lateral ventricle. There is hyperintense T2/FLAIR
signal changes within the medial right parietal lobe (11:15), which is new
from the prior study dated ___, with associated small focus of enhancement
(13:15), adjacent to cortical and subcortical FLAIR hyperintensity. This
likely reflects a subacute infarction
There is no mass effect or midline shift. There is no other abnormal
enhancement. The dural venous sinuses appear patent on post-contrast MPRAGE
images. The intracranial vascular flow voids are patent.
There is enlargement of bilateral pterygoid muscles, right greater than left,
with corresponding enhancement (100a: 28), which is new from the remote brain
MRI from ___. The edematous appearance of the pterygoid muscles is increased
when compared with the prior CT head from ___, without evidence of fatty
infiltration. Although the etiology of this is uncertain, the symmetry
suggests this may be inflammatory. Perhaps myositis after a seizure.
There is mucosal opacification of the left maxillary sinus with a mucosal
retention cyst, and mild opacification of bilateral ethmoid sinuses. The
remaining paranasal sinuses appear clear. There is mild opacification of
bilateral mastoid air cells with fluid. The orbits and soft tissues appear
unremarkable.
IMPRESSION:
1. Right parietal lobe subacute infarction.
2. No evidence of acute infarction, hemorrhage or mass.
3. Right basal ganglia chronic lacunar infarction.
4. Enlargement of bilateral pterygoid muscles with corresponding enhancement,
which is new from ___ and increased from ___. Given the absence of fatty
infiltration on CT, finding is felt most likely to be related to myositis,
perhaps related to a seizure.
NOTIFICATION: The findings were discussed with ___, M.D. by
___, M.D. on the telephone on ___ at 3:54 ___, 10
minutes after discovery of the findings.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with AMS found down s/p intubation with concern
for aspiration PNA // Please assess for interval change Please assess for
interval change
IMPRESSION:
ET tube tip is very low, and the level of the carina approximately 1 cm above
the carina and should be pulled back at least 4 cm. NG tube tip is in the
stomach. Heart size and mediastinum are stable but there is interval
development of left basal atelectasis most as well as right basal atelectasis
most likely due to abnormal position of the ETT. No vascular congestion. No
pulmonary edema.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 9:23 AM, 3 minutes after
discovery of the findings.
Radiology Report
EXAMINATION: RENAL U.S.
INDICATION: ___ year old woman with AMS, hypertensive emergency, decrease
urine output. // please do with Doppler, etiology of decreased urine output,
please assess for renal artery stenosis
TECHNIQUE: Grey scale, color and spectral Doppler ultrasound images of the
kidneys were obtained.
COMPARISON: None.
FINDINGS:
The right kidney measures 11.1 cm. The left kidney measures 11.7 cm. There is
no hydronephrosis, stones, or solid masses bilaterally. There is a dominant
central renal cyst within the left pelvis measuring 2.9 x 3.3 x 2.8 cm.
Normal cortical echogenicity and corticomedullary differentiation are seen
bilaterally.
Renal Doppler:
Right-sided intrarenal arteries demonstrate for visualization of flow,
although unclear whether this is of technical cause. Where visualized,
arterial upstrokes appear fairly brisk, although for assessment of diastolic
flow.
Intrarenal arteries on the left show normal waveforms with sharp systolic
peaks and continuous antegrade diastolic flow. The resistive indices of the
left intra renal arteries range from 0.7-0.8. The resistive indices on the
right are not well assessed.
Bilaterally, the main renal arteries are patent with normal waveforms. . Main
renal veins are patent bilaterally with normal waveforms.
The bladder is moderately well distended and normal in appearance.
IMPRESSION:
1. Suboptimal right renal arterial waveforms, although without overt tardus
parvus morphology. Overall diastolic flow on the right appears decreased,
although unclear whether this is technical in nature. If clinically needed,
consider either CTA or MRA for better assessment of renal arterial supply.
2. Left renal arterial waveforms are within normal limits.
3. Unremarkable morphologic appearance of the bilateral kidneys. Left renal
cyst.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with hypoxia // Evaluate for pulmonary edema
TECHNIQUE: Single frontal view of the chest
COMPARISON: ___.
IMPRESSION:
NG tube tip isin the stomach. ET tube is in standard position. The cuff
appears mildly hyperinflated. Cardiac size cannot be evaluated. There are
low lung volumes. Pulmonary arteries are enlarged consistent with pulmonary
hypertension. There is mild interstitial edema. Bibasilar opacities are
consistent with atelectasis increased from prior. .
Radiology Report
INDICATION: ___ year old woman with NGT // Eval for NGT placement
COMPARISON: Radiographs from ___
IMPRESSION:
Endotracheal tube has been removed. There is a nasogastric tube whose tip and
side port are below the GE junction appropriately sited. There is unchanged
cardiomegaly. There are low lung volumes. Pulmonary arteries are again
prominent. There is persistent pulmonary edema and bibasilar opacities which
may represent atelectasis or early infiltrate.
Radiology Report
EXAMINATION: VENOUS DUP UPPER EXT UNILATERAL LEFT
INDICATION: ___ year old woman with unilateral LUE edema, evaluate for DVT.
TECHNIQUE: Grey scale and Doppler evaluation was performed on the left upper
extremity veins.
COMPARISON: None.
FINDINGS:
There is normal flow with respiratory variation in the bilateral subclavian
vein.
The left internal jugular and axillary veins are patent, show normal color
flow and compressibility. The left brachial and basilic veins are patent,
compressible, and show normal color flow and augmentation. There is occlusive
thrombus of the distal left cephalic vein near the antecubital fossa.
IMPRESSION:
1. No evidence of deep vein thrombosis in the left upper extremity.
2. Superficial thrombophlebitis of the left cephalic vein at the level of the
antecubital fossa.
NOTIFICATION: The findings were discussed with ___, M.D. by
___, M.D. on the telephone on ___ at 3:10 ___, 1 minutes after
discovery of the findings.
Radiology Report
EXAMINATION: ___ DUP EXTEXT BIL (MAP/DVT)
INDICATION: ___ year old woman with persistent altered mental status with PFO
with concern for possible DVT, evaluate for DVT.
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the bilateral lower extremity veins.
COMPARISON: None.
FINDINGS:
There is normal compressibility, flow, and augmentation of the bilateral
common femoral, femoral, and popliteal veins. Within the left deep femoral
vein there is echogenic intraluminal material without documented color flow,
which extends slightly into the left common femoral vein. Normal color flow
and compressibility are demonstrated in the right posterior tibial and
peroneal veins. There is normal compressibility of the left posterior tibial
veins. The left peroneal veins could not be identified.
There is normal respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
Acute occlusive DVT in the left deep femoral vein, extending slightly into the
left common femoral vein, where it is nonocclusive.
NOTIFICATION: The findings were discussed with ___, M.D. by
___, M.D. on the telephone on ___ at 3:10 ___, 1 minutes after
discovery of the findings.
Radiology Report
INDICATION: ___ year old woman with fever and recent extubation. //
progression of infiltrate
COMPARISON: Radiographs from ___.
IMPRESSION:
Feeding tube is again seen. There is unchanged cardiomegaly. There is a
right perihilar opacity and left basilar opacity which have worsened. There is
mild pulmonary edema and likely small bilateral effusions. There are no
pneumothoraces.
Radiology Report
INDICATION: ___ year old woman with PNA in ICU no BMs in several days. // ?
obstruction
TECHNIQUE: Portable supine abdominal radiograph was obtained.
COMPARISON: None available.
FINDINGS:
There are no abnormally dilated loops of large or small bowel. The stomach is
distended.
Supine assessment limits detection for free air; there is no gross
pneumoperitoneum.
Osseous structures are notable for degenerative disease of the lumbar spine.
The enteric tube terminates in the stomach.
IMPRESSION:
No radiographic evidence of obstruction.
Radiology Report
EXAMINATION: UNILAT UP EXT VEINS US LEFT
INDICATION: ___ year old woman with known DVT now with right arm welling //
clot (right)
TECHNIQUE: Grey scale and Doppler evaluation was performed on the right upper
extremity veins.
COMPARISON: Left arm ultrasound ___
FINDINGS:
There is normal flow with respiratory variation in the subclavians veins
bilaterally.
The right internal jugular, axillary and brachial veins are patent, show
normal color flow and compressibility. The right basilic, and cephalic veins
are patent. Superficial edema is incidentally noted.
IMPRESSION:
No evidence of deep vein thrombosis in the right upper extremity. Superficial
edema incidentally noted.
Radiology Report
EXAMINATION: CHEST PORT. LINE PLACEMENT
INDICATION: ___ year old woman with new R PICC // R DL Power PICC 45cm ___
___ Contact name: ___: ___
TECHNIQUE: Chest single view
COMPARISON: ___ 10:04
FINDINGS:
Right PICC line tip at cavoatrial junction. Enteric tube tip well below
diaphragm, not included on the radiograph. Increased heart size, pulmonary
vascularity, stable since prior. Probable small bilateral pleural effusions,
similar. Bibasilar opacities, left lower lobe consolidation are stable.
Right perihilar opacity may represent asymmetric edema, similar. No
pneumothorax.
IMPRESSION:
New right PICC line. Otherwise stable.
Radiology Report
EXAMINATION: CT ABD AND PELVIS WITH CONTRAST
INDICATION: ___ year old woman admitted to ___ for pneumonia, found to have
bilateral lower extremity DVTs and upper extremity DVT. // Malignancy workup
for hypercoagulability
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technique.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence: 1) Stationary Acquisition 0.5 s, 1.0 cm; CTDIvol
= 1.2 mGy (Body) DLP = 1.2 mGy-cm. 2) Stationary Acquisition 7.5 s, 1.0 cm;
CTDIvol = 17.4 mGy (Body) DLP = 17.4 mGy-cm. 3) Spiral Acquisition 16.3 s,
62.7 cm; CTDIvol = 12.9 mGy (Body) DLP = 789.8 mGy-cm. Total DLP (Body) = 826
mGy-cm.
COMPARISON: None.
FINDINGS:
LOWER CHEST: Please refer to separate report of CT chest performed on the same
day for description of the thoracic findings.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. There
is no evidence of focal lesions. There is no evidence of intrahepatic or
extrahepatic biliary dilatation. The gallbladder is surgically absent.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: Right adrenal gland is normal in size and shape. There is a
homogeneously enhancing left adrenal nodule measuring 1.6 x 1.5 cm, 62 ___,
indeterminate.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There is no hydronephrosis. No focal lesions in the right kidney. There is a
4.8 cm simple cyst in the left kidney. There is no perinephric abnormality.
GASTROINTESTINAL: Enteric tube terminates in the body of the stomach. There is
mild stranding about the duodenum (5:62), which may represent duodenitis.
Small bowel loops otherwise demonstrate normal caliber, wall thickness, and
enhancement throughout. Colonic diverticulosis. The rectum is fluid-filled.
Normal appendix. No ascites.
PELVIS: There is post instrumentation air within the bladder. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: Uterus is unremarkable in appearance.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease
is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
Minimal anterolisthesis of L5 on S1 is noted.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. Mild fat stranding about the duodenum, may reflect duodenitis.
2. Homogeneously enhancing 1.6 x 1.5 cm left adrenal nodule is indeterminate,
but statistically likely an adenoma. If further characterization is desired,
a dedicated adrenal protocol CT or MRI could be obtained.
3. Diverticulosis.
4. CT chest dictated separately.
RECOMMENDATION(S): Consider adrenal protocol CT or MRI for further evaluation
of the left adrenal nodule.
NOTIFICATION: The findings and recommendation were discussed with ___
___, M.D. by ___, M.D. on the telephone on ___ at 5:48 ___,
15 minutes after discovery of the findings.
Radiology Report
EXAMINATION: CT CHEST W/CONTRAST
INDICATION: ___ female admitted for pneumonia with bilateral lower
extremity and upper extremity deep venous thromboses. Malignancy workup for
hypercoagulability.
TECHNIQUE: Multi detector CT images through the chest were performed after
the administration of intravenous contrast. Coronal and sagittal reformations
as well as axial maximum intensity projection reformations were generated and
reviewed.
DOSE: Acquisition sequence:
1) Stationary Acquisition 0.5 s, 1.0 cm; CTDIvol = 1.2 mGy (Body) DLP = 1.2
mGy-cm.
2) Stationary Acquisition 7.5 s, 1.0 cm; CTDIvol = 17.4 mGy (Body) DLP =
17.4 mGy-cm.
3) Spiral Acquisition 16.3 s, 62.7 cm; CTDIvol = 12.9 mGy (Body) DLP =
789.8 mGy-cm.
Total DLP (Body) = 826 mGy-cm.
** Note: This radiation dose report was copied from CLIP ___ (CT ABD AND
PELVIS WITH CONTRAST)
COMPARISON: None.
FINDINGS:
The imaged thyroid gland is homogeneous in attenuation without focal
nodularity. Scattered axillary nodes are not pathologically enlarged and
normal in morphology. A right PICC terminates within the right atrium.
Several mediastinal nodes are present. A right upper paratracheal node
measures 8 mm the level of the thoracic inlet (05:16). A right lower
paratracheal station node measures 7 mm (05:22). An aortopulmonary window
node measures 8 mm in diameter (05:22).
The ascending aorta is non aneurysmal. The main pulmonary artery is dilated
measuring up to 44 mm (05:25) suggestive of although not diagnostic for
pulmonary hypertension. Study is not designed for detection of pulmonary
emboli beyond the lobar level. Heterogeneity within a right lower lobe
pulmonary artery branch could very well reflect mixing artifact. There is no
pericardial effusion. Multi-chamber heart enlargement is moderate. Diffuse
coronary artery calcifications are moderately severe. Moderate calcifications
involve the aortic arch, origins of head and neck vessels, and descending
thoracic aorta. An enteric tube descends the thorax within the esophagus, its
tip incompletely imaged.
Small pleural effusions are nonhemorrhagic and layering, left greater than
right. Secretions are present within the trachea. Consolidation within the
left lower lobe and to a smaller degree the right lower lobe medially are
associated with air bronchograms, may be atelectatic in etiology. A heavy
volume of bronchocentric, ground-glass opacities is confined to the right
upper lobe, confluent above fissural thickening of the minor fissure, as best
appreciated on the sagittal reformations image 61.
There are no worrisome osseous lesions in the chest cage. Moderately severe,
compression fracture of the T10 vertebral body with depression of the anterior
and superior endplate is age indeterminate.
For complete subdiaphragmatic findings, please refer to CT abdomen and pelvis
performed concurrently, clip number ___.
IMPRESSION:
1. Predominantly right upper lobe alveolar abnormality is unlikely to be
asymmetric pulmonary edema, more likely infection and/or hemorrhage.
2. Bibasilar consolidation, left greater than right, likely atelectasis.
3. Small, bilateral layering, nonhemorrhagic pleural effusions..
4. Moderately severe, compression fracture of the T10 vertebral body is age
indeterminate.
5. Pulmonary artery enlargement is suggestive of although not diagnostic for
pulmonary hypertension.
6. For complete subdiaphragmatic findings, please refer to CT abdomen and
pelvis performed concurrently, clip number ___.
Radiology Report
EXAMINATION: MRI of the abdomen
INDICATION: ___ year old woman with resistant hypertension and adrenal mass on
CT scan. // protocol for adrenal
TECHNIQUE: T1 and T2 weighted images of the abdomen were acquired in a 1.5 T
magnet.
Intravenous contrast: 40 mL MultiHance.
COMPARISON: CT performed ___.
FINDINGS:
The exam is limited due to motion artifact.
Lower Thorax: The visualized lung bases demonstrate trace left pleural
effusion.
Liver: Visualized portions of the liver demonstrate normal contour. Hepatic
steatosis. No focal liver lesion is seen.
Biliary: Gallbladder is absent. No intrahepatic or extrahepatic biliary duct
dilatation.
Pancreas: Pancreas is unremarkable.
Spleen: Spleen is normal size. No focal splenic lesion.
Adrenal Glands: In the apex of the left adrenal gland, there is an 1.8 x 1.7
cm adrenal nodule. This demonstrates signal dropout on out of phase imaging
and is consistent with an adrenal adenoma. Right adrenal gland is normal.
Kidneys: The kidneys are normal size and symmetric. In the interpolar region
of the left kidney, there is a 5.1 cm cyst. No evidence of renal artery
stenosis. No accessory renal arteries.
Gastrointestinal Tract: Hiatal hernia. Thickening and edema of the second
portion of the duodenum, consistent with findings of duodenitis on prior CT.
Lymph Nodes: No enlarged lymph nodes.
Vasculature: Abdominal aorta is normal caliber. Mild atherosclerotic disease
is noted of the abdominal aorta. Mild narrowing of the origin of the celiac
axis.
Osseous and Soft Tissue Structures: Bone marrow signal intensity is normal.
IMPRESSION:
1. 1.8 cm left adrenal nodule is consistent with an adrenal adenoma.
2. No evidence of renal artery stenosis.
3. Hepatic steatosis.
4. Thickening and edema of the duodenum is consistent with duodenitis.
Gender: F
Race: HISPANIC/LATINO - DOMINICAN
Arrive by UNKNOWN
Chief complaint: Unresponsive
Diagnosed with Altered mental status, unspecified
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: 1.0 | Ms. ___ is a ___ year old female with PMH of HTN, HLD,
stroke, and OSA who was found down upon admission ___ the setting
of hypertensive emergency with SBPs 200s, admitted to the MICU
for hypertensive emergency with a hospital course notable for
refractory hypertension. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Falls, left leg weakness and numbness.
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mrs. ___ is a ___ y.o. right handed, ___ only speaking
woman, with no past medical history except for calcifications
seen on mammogram which have been followed, who is presenting
with a 1 week history of left lower extremity weakness,
numbness, and 3 falls in the context of dizziness.
Mrs. ___ has been in her usual state of health, until the last 2
weeks. She has been reporting some headaches and
lightheadedness, which is however not new or unusual for her.
She also noticed some weakness in her left leg. One week ago
(last ___, she was going upstairs at work when she suddenly
felt that she got dizzy, her vision got blurry, her left leg
felt numb and gave away. She fell towards the left, and landed
on her lower back. She reports that it took her about 10 minutes
for the lightheadedness (which did not have a vertigo
component), to go away. She has not had a loss of
consciousness. No SOB associated with this. Since then, she
has been reporting on and off paresthesias in her left leg,
sparing the foot, with cold sensation in her knee and shin. She
has also been reporting weakness in her "knee", and this has
been the same. The onset is however unclear. She has had
difficulty with gait and has noticed that she is dragging her
left leg.
She has been reporting lower back pain, mostly on the left side,
since her first fall.
On ___, she was walking up the stairs when she also had a
sensation of lightheadedness and fell. This sensation only
occurs with position change and never when she is sitting or
lying in bed.
On neuro ROS, she reports intermittent right ear tinnitus for
the last ___enies headache, loss of vision,
blurred vision, diplopia, dysarthria, dysphagia, vertigo,or
hearing difficulty. Denies difficulties producing or
comprehending speech. No bowel or bladder incontinence or
retention.
On general review of systems, the pt denies recent fever or
chills. No night sweats or recent weight loss or gain. Denies
cough, shortness of breath. Denies chest pain or tightness,
palpitations. Denies nausea, vomiting, diarrhea, constipation
or abdominal pain. No recent change in bowel or bladder habits.
No dysuria. Denies arthralgias or myalgias. Denies rash.
Past Medical History:
Abnormal mammogram in ___ with calcifications, no biopsy,
followed up and believed to be stable.
Social History:
___
Family History:
Negative for strokes.
Physical Exam:
Physical Exam on Admission:
Vitals: T: 99.2 P: 63 R: 18 BP:114/51 SaO2: 98%
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally. She has a positive leg raising test on the left.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Language is fluent with intact repetition
and comprehension. Normal prosody. Speech was not dysarthric
(per ___ interpreter understanding). Able to follow both
midline and appendicular commands. The pt. had good knowledge of
current events. There was no evidence of apraxia or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation. Funduscopic
exam revealed no papilledema, exudates, or hemorrhages.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Motor:
Normal bulk and tone, no rigidity or bradykinesia.
Left:
Delt ___, ___ ___, Tri ___, Grip ___, Spread ___, IP ___, Quad
___, Ham ___, TA 4+/5, ___ 4+/5, Gastroc 4+/5
Right:
Delt ___, ___ ___, Tri ___, Grip ___, Spread ___, IP ___, Quad
___, Ham ___, TA ___, ___ ___, Gastroc ___
-Sensory: Loss of sensation to light touch and pinprick in a
patchy L3 and L4 distribution in the left leg, in addition to
paraspinal areas on the right and left corresponding to L3.
There was an area of sensory loss on the left flank,
encompassing L1, T12, T10, T9, without involving the whole
dermatomes but only the left side of her torso. I was unable to
perform vibration and proprioception due to lack of time with
the ___ interpreter.
-Rectal tone normal, with normal anal wink, and no saddle
anesthesia.
Reflexes:
DTRs
Right: ___ 2 Tri 2 Brach2 Patellar 2 Achilles 1
Left: ___ 2 Tri 2 ___ 2 Patellar 2 Achilles 1
Plantar response was flexor bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF bilaterally.
-Gait: Good initiation. Narrow-based, normal stride and arm
swing. does drag her left foot. Rhomberg with mild sway to the
left.
Physical Exam on Discharge:
Neuro exam with ___ strength in L IP, hamstring, TA; ___ in all
other muscle groups in LEs and UEs. Sensation is intact to light
touch throughout, improved since admission.
Pertinent Results:
Labs on Admission:
___ 06:20PM WBC-7.1 RBC-3.82* HGB-11.8* HCT-36.3 MCV-95
MCH-30.9 MCHC-32.5 RDW-12.6
___ 06:20PM NEUTS-59.5 ___ MONOS-4.2 EOS-1.0
BASOS-0.5
___ 06:20PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-SM
___ 06:20PM GLUCOSE-86 UREA N-11 CREAT-0.6 SODIUM-139
POTASSIUM-3.8 CHLORIDE-104 TOTAL CO2-27 ANION GAP-12
___ 07:30AM WBC-6.0 RBC-3.87* HGB-12.2 HCT-36.7 MCV-95
MCH-31.7 MCHC-33.3 RDW-12.5
___ 07:30AM TRIGLYCER-134 HDL CHOL-47 CHOL/HDL-3.5
LDL(CALC)-89
___ 07:30AM %HbA1c-5.6 eAG-114
___ 07:30AM CHOLEST-163
___ 07:30AM GLUCOSE-96 UREA N-11 CREAT-0.6 SODIUM-138
POTASSIUM-4.2 CHLORIDE-103 TOTAL CO2-27 ANION GAP-12
Imaging:
Non Con Head CT
FINDINGS: There is no evidence of acute intracranial
hemorrhage, edema, mass, mass effect, or large vascular
territorial infarction. The ventricles and sulci are normal in
size and configuration. There is no shift of normally midline
structures. No acute fracture is detected. The middle ear
cavities, mastoid air cells, and included views of the paranasal
sinuses are clear. The right mastoid air cells are incidentally
noted to be underdeveloped (2:7).
IMPRESSION: No acute intracranial process.
MRI C/L/T spine w/ and w/o contrast
1. No evidence of cord signal abnormality.
2. Multiple levels of cord impingement in the cervical spine
caused by disc-osteophyte complexes, worst at c5/c6 and c6/7
where there is also left neural forminal narrowing.
3. Large annular tear with broadbase protrusion which
significantly indents the ventral theca at the L4/5 level and
the traversing the left L5 nerve root. It may also be contacting
the right L5 nerve root, but not impinging this.
4. In the lower T and L spine, no paraspinal or epidural
enhancing soft tissue mass. No pathologic or leptomengingeal
cord focus of enhancement. Patient could not complete post
contrast C-spine imaging.
5. No evidence of marrow replacement by cancer or epidural sot
tissue mass however diffusely abnormal bone marrow signal,
likely red marrow reconversion or osteopenia.
Medications on Admission:
none
Discharge Medications:
1. ___ stockings
2. Outpatient Physical Therapy
Evaluate and treat for left lower extremity weakness for
cervical and lumbar spondylosis with radiculopathy
Discharge Disposition:
Home
Discharge Diagnosis:
cervical spondylosis with neuropathy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Level of Consciousness: Lethargic but arousable.
Neuro exam with ___ strength in L IP, hamstring, TA; ___ in all
other muscle groups in LEs and UEs. Sensation is intact to light
touch throughout, improved since admission.
Followup Instructions:
___
Radiology Report
HISTORY: ___ woman with history of abnormal mammogram (but no history
of malignancy, per OMR), left lower extremity weakness and sensory, and back
pain. Query disc herniation versus malignant infiltration.
COMPARISONS: None.
TECHNIQUE: MRI of the entire spine, with and without contrast. N.B. The
patient could not tolerate the entire exam and only post-gadolinium imaging of
the lower thoracic and lumbar spine could be obtained.
FINDINGS: There is diffuse heterogeneous T1- and T2-hypointensity of the all
the veterbral bodies; while there is no evidence of marrow replacement by
malignancy, the diffuse bone marrow signal abnormality could be related to red
marrow reconversion (in response to anemia or systemic treatment) or
osteopenia. There is no spinal cord signal abnormality through the conus
medullaris, which is normal in morphology and terminates at the L2 level. The
imaged retroperitoneal and paraspinal soft tissues are unremarkable in overall
appearance.
In the lower T and L-spine, where post-gadolinium images were obtained, there
is no enhancing paraspinal or epidural soft tissue mass. There is no
pathologic leptomeningeal or intramedullary focus of enhancement.
CERVICAL SPINE: There are multiple levels of degenerative changes noted in
the cervical spine.
At C3/C4, there is central disc protrusion causing minimal compression of the
thecal sac but no foraminal narrowing.
At C4/C5, there is flattening of the thecal sac caused by broad-based
disc-osteophyte complex. There is also bilateral mild to moderate neural
foraminal narrowing at this level.
At C5/C6, there is disc protrusion which extends into the the proximal left
neural foramen and indents the spinal cord as well as narrows the left neural
foramen, impinging upon the exiting C6 nerve root (5:18).
At C6/C7, there is similar narrowing of the left intraforaminal zone and again
narrowing of the neural foramina, impinging upon the exiting C7 nerve root.
THORACIC SPINE: No significant degenerative changes are noted in the thoracic
spine.
LUMBAR SPINE: Again, there are multilevel, multifactoral degenerative changes
in the lumbar spine, worst at L4/L5.
In the L3 vertebral body, a somewhat rounded, well defined 1.4 x 1.1 cm T1-
and T2-hyperintense lesion does not parallel the endplate and its signal is
suppressed on "water" IDEAL images indicating a likely hemangioma. A similar,
although slightly larger 1.5 x 1.4 cm lesion in the L4 vertebra also likely
represents a hemangioma. Subtle ___ I and ___ changes are seen at the
anterior aspect of the L4 vertebral endplate.
At L4/L5, there is disc desiccation with a large transverse annular tear with
broad-based protrusion which significantly indents the ventral theca and
impinges upon the traversing left L5 nerve root (11:19). This also contacts
the traversing right L4 nerve root; however, the degree of impingement is not
nearly as severe on this side. At this level, there is also ligamentum flavum
thickening, facet arthrosis and a significant narrowed subarticular recess
At L5/S,1 there is again disc desiccation and a a small transversely-oriented
annular tear with an accompanying protrusion which barely abuts the traversing
S1 nerve roots.
IMPRESSION:
1. No evidence of spinal cord signal abnormality.
2. Multilevel cord deformity in the cervical spine caused by disc-osteophyte
complexes, most severe at C5/C6 and C6/C7, where there is also significant
left neural foraminal narrowing with impingement upon the exiting left C6 and
C7 nerve roots.
3. Multilevel degenerative disease in the lumbar spine, most marked at the
L4/L5 level where a large annular tear with accompanying broad-based
protrusion indents the ventral thecal sac and significantly impinges upon the
traversing left L5 nerve root.
4. In the lower T- and the L-spine, no enhancing paraspinal or epidural soft
tissue mass. No pathological or leptomeningeal, intramedullary or radicular
focus of enhancement. (The patient could not tolerate post-contrast C-spine
imaging.)
5. No evidence of marrow replacement by malignancy. However, the diffusely
abnormal bone marrow signal may be due to red marrow reconversion,
myeloproliferative disorders or osteopenia, and should be correlated
clinically.
COMMENT: These findings were discussed with the requesting provider, Dr.
___ (Neurology service), by Dr. ___ via telephone, at 5:25
p.m. on the day of the study.
Gender: F
Race: ASIAN - CHINESE
Arrive by WALK IN
Chief complaint: HYPOTENSION/FALLING
Diagnosed with OTHER MALAISE AND FATIGUE, HEADACHE
temperature: 99.2
heartrate: 63.0
resprate: 18.0
o2sat: 98.0
sbp: 114.0
dbp: 51.0
level of pain: 13
level of acuity: 3.0 | Mrs. ___ is a ___ y.o. right handed, ___ only speaking
woman, with no past medical history except for calcifications
seen on mammogram which have been followed, who is presenting
with a 1 week history of left lower extremity weakness,
numbness, and 3 falls in the context of dizziness.
# Neuro: On exam, patient does have weakness and objectively
decreased sensation. Here strength in LLE is reduced with IP 4,
ham 4 ta 4. She has decreased sensation in L3/L4 in LLE, T12
level in sensation anteriorly and T10 posteriorly. Initially
had some concern for metastatic disease to the spine give
history of calcifications seen on mammogram in the past, but
this was ruled out. MRI C/T/L spine with and without contrast
showed diffuse C spine spondylosis. Multiple levels of cord
impingement in the cervical spine caused by disc-osteophyte
complexes, worst at c5/c6 and c6/7 where there is also left
neural forminal narrowing. She also had a large annular tear
with broadbase protrusion which significantly indents the
ventral theca at the L4/5 level and the traversing the left L5
nerve root. We advised on discharge that patient wear cervical
collar 24 hours per day and not lift more than 10 lbs. In
regards to the falls, further history was obtained and sounds
like her lightheadedness is positional. She was indeed
orthostatic by heart rate. Advised that she drinks more fluids
and consumes salt, for example, a bowl of soup daily, to
maintain an adequate intravascular volume. Mrs. ___ is a nanny
for 4 children. Asked her to refrain from working until she is
re-evaluated in neurology clinic. Physical therapy evaluated
patient and felt that she was safe to go home with outpatient
___. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Ace Inhibitors
Attending: ___.
Chief Complaint:
cough, fever
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The patient is a ___ year old man w ___ CAD s/p MI w PCI,
ischemic cardiomyopathy with EF ___, h/o VT with ICD in
place, h/o L ventricular apical thrombus on A/C, CKD, suspicion
for prostate ca, p/w fever and worsening cough. The patient
noted fever to 102.4 the night prior to presentation. He has had
a cough over the past ___ weeks, which worsened acutely over the
past week/few days. For the past couple of nights the cough has
been so bad that it kept him up at night. The cough is
productive of white/yellow sputum with streaks of blood. He has
also felt increasingly SOB for the past few weeks which he
mostly notices when going up stairs. Denies chills, sweats,
chest pain, recent ICD firinng. he had some nausea associated
with coughing but no vomiting. No diarrhea. No URI sx, no sick
contacts.
Of note he was supossed to follow up with outpatient pulmonology
for evaluation of his ongoing cough. His PCP had recommended he
get PFTs. There was some concern for possible amiodarone
toxicity leading to chronic cough.
In the ED VS were 97.6 100.9 107/71 18 98% ra. CXR showed R
middle lobe pneumonia. EKG unchanged from prior. He recieved
Furosemide 20 mg PO, fluticasone, Azithro 500, CTX 1 gram,
Tylenol 1 gram. Labs showed INR 1.8 Cr 1.4, K 3.1. He was
admitted to medicine with pneumonia.
Past Medical History:
- ischemic cardiomyopathy, CHF- EF ___
- ICD in place (St. ___ V193). history ofnmultiple shocks
in ___, was quiet after that on amiodarone therapy
- s/p MI with 3VD. PCI x2 ___, s/p PTCA/stenting of the LAD
and s/p PCI in ___ to LCX
- Hypertension.
- Hyperlipidemia.
- History of left ventricular apical thrombus, status post
Coumadin therapy. This was noted on his echo note dated
___. It is postulated that this has endotheliazed and not
at major risk for embolic phenomenon.
- ___ mitral regurgitation.
- History of heavy alcohol use.
- Chronic kidney disease with a baseline creatinine around 1.7.
An SPEP and a UPEP were negative. This was attributed to
vascular disease.
- History of supraventricular tachycardia.
- Status post excision of facial basal cell carcinoma.
- Osteoarthritis.
- GERD.
- Questionable history of gout. Had rheumatology evaluation in
___ with no evidence of gout.
- Iron deficiency anemia.
- Elevated PSA and patient, thought to be ___ prostate ca,
patient deferred further work up.
- History of vasectomy.
- History of ? left eye embolic phenomenon
- Basal cell ca of the skin, s/p excision
- chronic back pain
Social History:
___
Family History:
Three maternal uncles died suddenly before being ___ old.
Father died at ___ of CHF. Otherwise ___.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 98.9 117/74 85 22 97%RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no JVP at clavicle at 45 degrees
Lungs: Rhoncherous transmitted upper respiratory sounds. No
weezes or crackles, good air movement throughout.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, ___, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis. 1+
edema R>L. Per patient this is not far off from his baseline.
ADMISSION PHYSICAL EXAM:
Vitals: Tm ___ yest evening 98.5 117/86 % RA
Weight 108-->107.6-->106.3--> 107.1 today
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP elevated to 1 cm above the clavicle at 90
degrees
Lungs: Rhoncherous transmitted upper respiratory sounds,
increaed at the R lung base. No weezes or crackles, good air
movement throughout.
CV: Regular rhythm at about 100 Bpm, normal S1 + S2, no murmurs,
rubs, gallops
Abdomen: soft, ___, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis. 1+
___ edema R>L.
Pertinent Results:
ADMISSION LABS
___ 10:06PM URINE ___
___ 10:06PM URINE GR ___
___ 10:06PM URINE ___ SP ___
___ 10:06PM URINE ___
___
___ 10:06PM URINE ___ WBC-<1 ___
___
___ 10:06PM URINE ___
___ 11:20AM ___ UREA ___
___ TOTAL ___ ANION ___
11:20AM ___ this
___ 11:20AM cTropnT-<0.01
___ 11:20AM ___
___ 11:20AM VIT ___
___ 11:20AM ___
___
___ 11:20AM ___
___
___ 11:20AM ___ ___
___ 11:20AM PLT ___
Bcx ___ - pending, no growth to date
___ 10:06 pm URINE Source: ___.
**FINAL REPORT ___
Legionella Urinary Antigen (Final ___:
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
(Reference ___.
Performed by Immunochromogenic assay.
A negative result does not rule out infection due to other
L.
pneumophila serogroups or other Legionella species.
Furthermore, in
infected patients the excretion of antigen in urine may
vary.
___ 12:05 am URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
Sputum Cx x 2 -- non diagnostic specemin
CXR ___
Findings consistent with pneumonia. ___ radiographs are
recommended to show resolution within eight weeks.
CXR ___
1. Worsening pneumonia, mostly in the right middle and lower
lobes with a new focal right perihilar consolidation.
2. Separate from these findings is an apparently slowly growing
nodule in the right upper lobe. Radiographic follow up within 8
weeks is recommended for evaluation of interval resolution of
the ___ right middle/lower lobe pneumonia. If
increase in right upper lobe nodule size persists at that time,
further followup is recommended with CT.
DISCHARGE LABS
___ 07:20AM BLOOD ___
___ Plt ___
___ 07:20AM BLOOD Plt ___
___ 07:20AM BLOOD ___ ___
___ 07:20AM BLOOD ___
___
___ 01:15PM BLOOD ___
___ 01:15PM BLOOD ___
___ 07:20AM BLOOD ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amiodarone 200 mg PO DAILY
hold for SBP < 100
2. Clopidogrel 75 mg PO DAILY
3. Fluticasone Propionate NASAL 1 SPRY NU BID
4. Furosemide 40 mg PO DAILY
5. Metoprolol Succinate XL 50 mg PO DAILY
hold for SBP < 100, HR < 60
6. Rosuvastatin Calcium 10 mg PO DAILY
7. Spironolactone 25 mg PO DAILY
hold for SBP < 100
8. Valsartan 40 mg PO DAILY
hold for SBP < 100
9. Warfarin 5 mg PO 4X/WEEK (___)
10. Warfarin 2.5 mg PO 3X/WEEK (___)
11. Aspirin 81 mg PO DAILY
12. FoLIC Acid 1 mg PO DAILY
13. Cyanocobalamin ___ mcg PO DAILY
Discharge Medications:
1. Amiodarone 200 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Clopidogrel 75 mg PO DAILY
4. Cyanocobalamin ___ mcg PO DAILY
5. Fluticasone Propionate NASAL 1 SPRY NU BID
6. FoLIC Acid 1 mg PO DAILY
7. Furosemide 40 mg PO DAILY
8. Metoprolol Succinate XL 50 mg PO DAILY
9. Rosuvastatin Calcium 10 mg PO DAILY
10. Spironolactone 25 mg PO DAILY
11. Valsartan 40 mg PO DAILY
12. Benzonatate 100 mg PO TID
RX *benzonatate 100 mg 1 capsule(s) by mouth three times a day
Disp #*21 Capsule Refills:*0
13. ___ Phosphate 10 mL PO Q6H cough
Do not drive or operate heavy machinery while taking this
medication
RX ___ 100 ___ mg/5 mL 10 mL by mouth every 6
hours as needed Disp #*1 Bottle Refills:*0
14. Acetaminophen 500 mg PO Q6H:PRN pain, fever
do not exceed 2 grams daily
15. Thiamine 100 mg PO DAILY
RX *thiamine HCl 100 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
16. Multivitamins 1 TAB PO DAILY
RX *multivitamin 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
17. Outpatient Lab Work
___: Please draw INR and fax results to ___ ___
clinic at ___. If drawn at a ___ facility, please
be sure to draw and fax labs before noon.
18. Levofloxacin 750 mg PO DAILY Duration: 2 Doses
___ and ___ are the last 2 doses
RX *levofloxacin 750 mg 1 tablet(s) by mouth daily Disp #*2
Tablet Refills:*0
19. Warfarin 2.5 mg PO ONCE Duration: 1 Doses
take on ___, have labs drawn on ___ and follow up
with ___ clinic for dosing
20. Outpatient Lab Work
___: please draw serum ___ and fax results to fax #
___ (phone # ___
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis
1. community acquired pneumonia
2. chronic systolic congestive heart failure
Secondary diagnosis
1. history of left ventricular apical thrombus on
anticoagulation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Patient with shortness of breath, cough, and fever. Evaluate for
acute cardiopulmonary process.
COMPARISONS: Multiple prior chest radiographs, most recent ___.
TECHNIQUE: PA and lateral chest radiographs.
FINDINGS: The lungs are well expanded. An opacity in the right lower lung
field obscuring the right heart border is new compared with prior exam.
Opacities are mostly in the right middle lobe although there is also
coinciding right lower lobe subpleural opacity. The remaining lung parenchyma
is unremarkable. There is no pleural effusion or pneumothorax. Mild
cardiomegaly stable. A single-lead pacemaker in the left hemithorax is
unchanged.
IMPRESSION: Findings consistent with pneumonia. Follow-up radiographs are
recommended to show resolution within eight weeks.
Radiology Report
INDICATION: ___ male patient with pneumonia and continued high
fevers. Study requested to rule out worsening pneumonia, abscess and/or
pleural effusion.
COMPARISON: Prior chest radiograph from ___ through ___.
TECHNIQUE: PA and lateral chest radiographs.
FINDINGS: As compared to prior radiograph from ___, there has been
interval worsening. There is increased opacification of the right heart border
and right hemidiaphragm, concerning for worsening pneumonia, mostly at the
right middle and lower lobes. There is a new right perihilar consolidation.
There is no pleural effusion or pneumothorax. Cardiomegaly is unchanged. A
single-channel pacemaker lead terminates in the right ventricle.
At the intersection of the right second anterior rib and the right fifth
posterior rib there is a linear and nodular opacity which has apparently
increased compared to prior examination from ___ and appears
separate from the above findings.
IMPRESSION:
1. Worsening pneumonia, mostly in the right middle and lower lobes with a new
focal right perihilar consolidation.
2. Separate from these findings is an apparently slowly growing nodule in the
right upper lobe. Radiographic follow up within 8 weeks is recommended for
evaluation of interval resolution of the above-described right middle/lower
lobe pneumonia. If increase in right upper lobe nodule size persists at that
time, further followup is recommended with CT.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: FEVERS/COUGH
Diagnosed with PNEUMONIA,ORGANISM UNSPECIFIED
temperature: 97.6
heartrate: 100.0
resprate: 18.0
o2sat: 98.0
sbp: 107.0
dbp: 71.0
level of pain: 0
level of acuity: 3.0 | The patient is a ___ year old man w ___ CAD s/p MI w PCI,
ischemic cardiomyopathy with EF ___, h/o VT with ICD in
place, h/o L ventricular apical thrombus on A/C, CKD, suspicion
for prostate ca, chronic cough, p/w PNA.
# CAP: The patient p/w fever and worsening of chronic cough sx.
No sick contacts, no URI sx. Hemodynamically stable without
elevated WBC count. Got azithro and CTX on ___ in the ED,
started on levofloxacin ___. Legionella urinary antigen
negative. BCx no growth to date but pending at ___. Patient
improved after several days of therapy, afebrile. The patient
was discharged with levofloxacin for total of 7 days of therapy
(first day ___, last day ___. ___ got tesslon pearls and
___ standing.
- recommend repeat CXR in ___ weeks to document resolution of
PNA
# Lung nodule: RUL seen on CXR
- recommend outpatient follow up of nodule, may consider CT scan
# chronic systolic CHF w EF ___: ___ ischemic cardiomyopathy.
S/p MI with 3VD and multiple PCI. ICD in place. The patient had
prior episodes of VT, recently fewer since he has been on
amiodarone and metoprolol. Euvolemic on exam on admission. He
became slightly dry during admission from insensible losses from
fevers. Lasix was held, and he subsequently became slightly
volume up with some mild hyponatremia (see below). At discharge
the patient was continued on lasix daily, and set up with heart
failure follow up (to clarify lasix dosing, since he usually
takes it once per day but is prescribed as BID). cont asa,
plavix, spironolactone, metoprolol, amiodarone, valsartan,
rosuvastatin.
# Hyponatremia: The patient became hyponatremic to 129 after a
day of holding lasix. The patient seemed volume overloaded on
exam, lasix was resumed, free water restriction was instituted,
and the hyponatermia had improved to 130 just a few hours later.
___ will be drawn on ___ and faxed to PCP for follow up for
resolution of this issue.
- outpaient PCP follow up, ___ will be drawn on ___ and faxed to
PCP
# ___ thrombus: on A/C. Had not taken Coumadin for several
days prior to admission. INR initially subterepeutic, then
became supratherepeutic with iniation of home regimin. Dose of
coumadin was held on day of discharge. He was instructed to take
2.5 mg on the day after admission and have INR drawn on ___
with follow up with ___ clinic.
- outpatient follow up with ___ clinic, next INR will be
drawn ___
# Chronic cough: PCP recommends outpatient pulm f/u for chronic
cough with PFTs and eval for possible amiodarone toxicity. At
discharge outpatient f/u with pulm was established. Amiodarone
was continued given good control of VT.
- recommend outpatient follow up with pulmonology, PFTs
recommended, consider possible amiodarone toxicity as etiology
of ongoing cough
# CKD: Cr 1.3 improved from baseline of 1.7
# Alcohol use: The patient reports being a "big drinker", and
drinks at least ___ drinks per night. He was initially placed on
CIWA but showed no signs of withdrawl. He was discharged on MVI,
folate, thiamine, B12
# B12 deficiency: patient reports improved gait with B12
supplimentation. B12 now repleted based on labs. cont B12,
folate
# post nasal drip and GERD: cont fluticasone nasal spray
# CODE: Full, confirmed
# CONTACT: ___
TRANSITIONAL ISSUES
- outpaient PCP follow up, ___ will be drawn on ___ and faxed to
PCP
- outpatient follow up with ___ clinic, next INR will be
drawn ___
- recommend repeat CXR in ___ weeks to document resolution of
PNA
- recommend outpatient follow up with pulmonology, PFTs
recommended, consider possible amiodarone toxicity as etiology
of ongoing cough
- consider outpatient CT chest to further charactize lung nodule |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
lisinopril
Attending: ___.
Chief Complaint:
cough
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HISTORY OF PRESENT ILLNESS:
Ms. ___ is a ___ y/o female with a history of HTN,
HLD, and pre-diabetes who presents with one day of cough. The
patient notes that she started having a dry cough yesterday. She
then has coughing spells which then result in her developing
substernal burning pain and trouble catching her breath. The
chest discomfort and SOB will last for about ___ minutes after
her coughing spell and then gradually resolve. She dose not have
any chest pain outside of these episodes and is not associated
with exertion. She denies a history of asthma or GERD. No fever
or chills. No orthopnea, PND, DOE, ___ edema. She also notes 2
episodes of post-tussive emesis (NBNB).
In the ED initial vitals were: 98.7 ___ 16 100%
- Labs were significant for WBC 13.2 with 73% polys, normal
chem-7, normal LFTs, troponin negative, d-dimmer negative.
- EKG showed SR at 105 with ~1mm STE in V1-V2, TVI in III with
no prior. CXR showed a mild retrocardiac opacification which
could represent pneumonia
- Patient was given 1L IVFs and levofloxacin.
On the floor, the patient reports that she is feeling well. She
has no specific complaints at this time. She is no longer
experiencing the chest discomfort or SOB. Not currently
coughing. She has had mild congestion, but no other URI
symptoms.
Review of Systems:
(+) per HPI
(-) fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, abdominal pain, nausea,
vomiting, diarrhea, constipation, BRBPR, melena, hematochezia,
dysuria, hematuria.
Past Medical History:
-HTN
-HLD
-pre-diabetes
-colon adenoma
-obesity
-lichen planus
-vitamin d deficency
Social History:
___
Family History:
Mother - DM
Father - unknown
Sister - DM
Brother - DM
Physical Exam:
EXAM ON ADMISSION:
===============
Vitals - T: 97.9 BP: 168/87 HR: 102 RR: 16 02 sat: 100% RA
GENERAL: well appearing pleasant ___ y/o female in NAD
HEENT: NCAT, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, good dentition
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding
EXTREMITIES: no edema, moving all 4 extremities with purpose
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact, strength ___ throughout, sensation
intact to light touch
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
EXAM ON DISCHARGE:
===============
Vitals - T: 97.8-97.9 BP: 152-168/87 HR: 102-113 RR: ___ 02
sat: 100% RA
GENERAL: well appearing pleasant ___ y/o female who appears
younger than stated age, in NAD
HEENT: NCAT, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, good dentition
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB with the exception of bibasilar crackles, no wheezes,
rales, rhonchi, breathing comfortably without use of accessory
muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding
EXTREMITIES: no edema, moving all 4 extremities with purpose
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact, strength ___ throughout, sensation
intact to light touch
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
LABS ON ADMISSION:
===============
___ 09:10PM BLOOD WBC-13.2* RBC-4.48 Hgb-13.7 Hct-40.7
MCV-91 MCH-30.7 MCHC-33.7 RDW-14.5 Plt ___
___ 09:10PM BLOOD Neuts-72.6* ___ Monos-6.0 Eos-2.0
Baso-0.8
___ 09:10PM BLOOD ___ PTT-34.5 ___
___ 09:10PM BLOOD Glucose-113* UreaN-17 Creat-1.1 Na-142
K-3.8 Cl-104 HCO3-23 AnGap-19
___ 09:10PM BLOOD ALT-26 AST-31 AlkPhos-88 TotBili-0.6
___ 09:10PM BLOOD cTropnT-<0.01
___ 09:10PM BLOOD Albumin-4.5 Calcium-9.7 Phos-3.3 Mg-2.2
LABS ON DISCHARGE:
===============
___ 07:00AM BLOOD WBC-11.3* RBC-4.50 Hgb-13.4 Hct-40.6
MCV-90 MCH-29.8 MCHC-33.1 RDW-14.5 Plt ___
___ 07:00AM BLOOD Glucose-103* UreaN-13 Creat-1.0 Na-144
K-4.2 Cl-105 HCO3-28 AnGap-15
___ 07:00AM BLOOD CK(CPK)-701*
___ 07:00AM BLOOD CK-MB-4 cTropnT-<0.01
___ 07:00AM BLOOD Calcium-9.8 Phos-3.1 Mg-2.0
STUDIES:
=======
CXR ___:
FINDINGS:
The heart is normal in size. The mediastinal and hilar contours
appear within
normal limits. The lung volumes are low with mild elevation of
the right
hemidiaphragm. Patchy opacities at the lung bases are probably
compatible with
atelectasis, and not out of proportion to reduced lung volumes,
but potential
are infectious.
IMPRESSION:
Mild retrocardiac opacification, atelectasis versus pneumonia.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. irbesartan 150 mg oral daily
2. estradiol 0.01 % (0.1 mg/gram) vaginal daily
3. Atorvastatin 80 mg PO DAILY
4. Vitamin D ___ UNIT PO DAILY
Discharge Medications:
1. Vitamin D ___ UNIT PO DAILY
2. estradiol 0.01 % (0.1 mg/gram) vaginal daily
3. irbesartan 150 mg oral daily
4. Azithromycin 250 mg PO Q24H
RX *azithromycin [Zithromax Z-Pak] 250 mg 1 tablet(s) by mouth
daily Disp #*6 Tablet Refills:*0
5. Albuterol Inhaler ___ PUFF IH Q6H:PRN shortness of breath
Please take this for shortness of breath of cough as needed
RX *albuterol sulfate [ProAir HFA] 90 mcg ___ puffs every 6
hours PRN shortness of breath Disp #*1 Inhaler Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Asthma/Reactive Airway Disease
Elevated CK
Secondary
Hyperlipidemia
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST RADIOGRAPHS
INDICATION: Cough and chest pain.
COMPARISON: None.
TECHNIQUE: Chest, PA and lateral.
FINDINGS:
The heart is normal in size. The mediastinal and hilar contours appear within
normal limits. The lung volumes are low with mild elevation of the right
hemidiaphragm. Patchy opacities at the lung bases are probably compatible with
atelectasis, and not out of proportion to reduced lung volumes, but potential
are infectious.
IMPRESSION:
Mild retrocardiac opacification, atelectasis versus pneumonia.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with history of cough and previous
opacification on CXR. // compare to prior
COMPARISON: ___.
IMPRESSION:
Cardiomediastinal contours are normal. The lungs are currently clear, with no
evidence of pneumonia.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Chest pain, Vomiting
Diagnosed with PNEUMONIA,ORGANISM UNSPECIFIED, HYPERTENSION NOS
temperature: 98.7
heartrate: 111.0
resprate: 16.0
o2sat: 100.0
sbp: 163.0
dbp: 110.0
level of pain: 4
level of acuity: 3.0 | Ms. ___ is a ___ y/o female with a history of HTN,
HLD, and pre-diabetes who presented with one day of coughing
fits associated with substernal chest burning, SOB, and post
tussive emesis in the context of having started a new job three
weeks ago in a ___ facility.
# Cough
Patient's dry cough with shortness of breath and chest
discomfort in the setting of recently starting a new job with
environmental dust exposure was concerning for possible asthma
exacerbated by environmental allergens . Patient given albuterol
inhaler which was also noted to alleviate cough. Pneumonia also
thought as potential etiology of cough given that patient
presented with leukocytosis of 13.2 and mild retrocardiac
opacification on CXR. The patient received one dose of levaquin
upon admission. However patient denied any recent viral
prodrome, myalgia, fever, or chills. However given some
likelihood of pneumonia patient discharged on 5 day course of
azithromycin. In addition patient discharged with PRN albuterol
inhaler. Should have more formal outpatient work up and
diagnosis of asthma with PFT's as outpatient.
#Chest pain
Patient's associated chest pain in context of cough was also
further evaluated and determined to be non-cardiac in origin.
Trop trended and were negative. EKG obtained without obvious
evidence of new ischemia. Only notable for sinus tachycardia
with nonspecific T wave changes. Upon chart review ___ EKG from
Atrius was notable for anteroseptal MI (age indeterminent). PE
also considered and D- dimer was within normal limits.
# Elevated CK
CK found to be elevated to 701. Patient denied any myalgias and
renal function was uncompromised. Elevated CK was concerning in
setting of atorvastatin 80 mg started in ___ and as
such it was stopped. In addition given that azithromycin has
theoretic interaction with atorvastatin it was also thought
prudent to hold this until azithromycin dose complete. It is
important to note that the CK level was elevated before starting
azithromycin. CK level should be repeated as outpatient and
restarting atorvastatin considered at that time.
# HTN
Patient remained with systolic blood pressure in the
150's-160's. Irbesartan continued.
# HLD
Atorvastatin stopped as above.
# Vitamin D Deficiency
Vit D continued. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Pedestrian struck
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ year old male who presents to the emergency
department after being struck by a motor vehicle reported to be
moving at ___ MPH. There was positive loss of consciousness
at
the scene. The patient was taken to the ___ emergency
department and intubated. There is no family available at the
time of this consultation for further history of the events.
Prior to the intubation the patient was given etomidate and
succinylcholine. The patient was also administered fentayl and
bolus' of versed due to agitation
Past Medical History:
laprascopic hernia repair
Social History:
___
Family History:
NC
Physical Exam:
O: T:99 BP: 122/76 HR:60 R:20 O2Sats99% ventilated
Gen: intubated and recently medicated with etomidate,
succinylcholine, fentanyl,versed
HEENT:No Battle sign, No ottohea, No rhinorrhea. left forehead
laceration, ecchymotic left eye Pupils: 2.5-2mm EOMs not
able to test due to sedation/mental status
Neck: hard cervical collar in place
Extrem: Warm and well-perfused .localizing equally with upper
extremities and moving all four extremities antigravity to
noxious stimulus. no commands
Neuro:
Mental status: no commands, no eye opening, intubated GCS 7 T
following multiple versed boluses.
Orientation/Recall/Language: intubated with recent trauma
patient
unable to perform at this time
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light,2.5 to 2mm
mm bilaterally. Visual fields - unable to assess
III, IV, VI: Extraocular movements- unable to assess
V, VII: Facial strength- grossly intact
VIII, IX, X, XI, XII: unable to test due to sedation and current
mental status
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. localizing equally with upper extremities and moving
all
four extremities antigravity to noxious stimulus. no commands
Toes mute
PHYSICAL EXAM ON DISCHARGE:
AVSS
Gen: WD/WN, comfortable, NAD.
HEENT: Atraumatic, normocephalic. PERRLA. EOMs intacat
Neck:immobilized by cervical collar
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Cranial Nerves:
II-XII intact
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power ___ to left upper and lower
extremities. Full stregnth to RLE extremity. RUE deltoid ___,
bicep 4+/5, tricep ___, grip ___. No pronator drift
Sensation: Intact to light touch
Babinki's negative. No clonus
Pertinent Results:
CT C-spine ___:
1. Left hard palate lucency concerning for a fracture. A
dedicated facial
series would be helpful to further assess extent of injury.
2. Right occipital condyle fracture.
3. Prevertebral soft tissue thickening raises concern for an
underlying
ligamentous injury. MR is recommended to further assess.
CT head ___:
1. No intracerebral hemorrhage. 2. Left frontal bone fracture
with extra conal air, irregularity of the medial wall of the
orbit and probable extension of the fracture to the sinuses
posteriorly. 3. Left frontal subgaleal hematoma
CT Chest/abdomen/pelvis ___:
1. Subtle fragmentation of the right transverse processes at L1
is likely
chronic. Clinical correlation for focal pain is recommended.
2. Bibasilar atelectasis.
3. No acute intra-abdominal or pelvic injury.
CT Max/Face ___:
1. Frontal bone fracture extending through the left frontal
sinus, left
maxillary sinus and contiguous with a left hard palate fracture
line. No
pneumocephalus.
2. Left superior orbital extraconal hematoma and left-sided
proptosis.
3. Right occipital condyle fracture.
MRI C-Spine ___:
1. Prevertebral edema in the upper cervical spine with edema of
the anterior longitudinal ligament from C2-3 through C5-6, and
edema of the posterior longitudinal ligament from C1-2 through
C3-4. Interspinous ligament edema from the craniocervical
junction through C6-7, with adjacent posterior paravertebral and
suboccipital muscle edema.
2. Acute spinal cord edema versus chronic myelomalacia at C3-4,
where the
spinal cord is deformed by a disc osteophyte complex which
results in moderate spinal canal stenosis.
3. 12 mm oval fluid-intensity structure in the distal left T1-2
neural
foramen and extraforaminal space, which may represent a nerve
root sleeve
diverticulum, but traumatic avulsion of the T1 nerve root cannot
be excluded. please correlate clinically.
4. Bone marrow edema along the superior endplate of the T4
vertebral body
without loss of height, which may indicate a bone contusion or a
non-displaced fracture. Bone marrow edema along the known right
occipital condyle fracture.
Right shoulder x-ray ___:
Two projections performed as a portable radiograph are provided.
The assessment is limited. The right humeral head is in correct
position. On the current images, there is no convincing
evidence of a fracture at the level of the right shoulder.
Again documented are known rib fractures, as seen on a CT torso
examination from ___ with multiple rib fractures and
pleural calcifications.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H:PRN pain
2. Docusate Sodium 100 mg PO BID
3. Senna 1 TAB PO BID
4. Gabapentin 300 mg PO TID
RX *gabapentin 300 mg 1 capsule(s) by mouth three times a day
Disp #*90 Capsule Refills:*0
5. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*80 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
-Anterior longitudinal ligmanet and posterior longitudinal
ligmament injury
-Cervical cord contusion at C3-4
-R occipital condyle fx
-L1 transverse process fx
-L Frontal bone fracture extending through the left frontal
sinus, left maxillary sinus and contiguous with a left hard
palate fracture line
Left superior orbital extraconal hematoma and left-sided
proptosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
HISTORY: Pedestrian struck. Rule out injury.
COMPARISON: None.
FINDINGS: The overlying trauma board limits evaluation. An endotracheal tube
is in satisfactory position, 3.5 cm above the carina. A density projecting
over the right clavicle could reflect a foreign object.
No pleural effusion, pneumothorax or focal airspace consolidation. The
cardiac size and mediastinum are unremarkable on this study. A large pleural
calcification is seen along the lateral right hemithorax.
Radiology Report
HISTORY: Pedestrian struck, unknown history, noncommunicative. Rule out
injury.
COMPARISON: None available.
TECHNIQUE: Axial CT images were obtained through the brain without IV
contrast. Coronal, sagittal and thin bone algorithm reconstruction were
generated.
FINDINGS:
There is no hemorrhage, major vascular territory infarction, edema, mass or
shift of normally midline structures. The ventricles and sulci are normal in
size and configuration. The basal cisterns appear patent and there is
preservation of gray-white matter differentiation.
There is a fracture at the left frontal bone probably extending to the
sinuses, given the presence of air within the ethmoid sinuses. There pockets
of air within the extra Conal region and anterior to the globe on the left.
There is irregularity of the medial wall of the orbit and opacification of the
left frontal sinus, ethmoid air cells and right sphenoid sinus. The mastoid
air cells are clear. There is a small left frontal subgaleal hematoma. There
is a small left superior orbital extraconal hematoma.
IMPRESSION:
1. No intracerebral hemorrhage. 2. Left frontal bone fracture with extra
conal air, irregularity of the medial wall of the orbit and probable extension
of the fracture to the sinuses posteriorly. 3. Left frontal subgaleal
hematoma.
Findings discussed with Dr. ___ (neurosurgery), by ___
___ in person at 9:01 AM, time of discovery.
Radiology Report
HISTORY: Pedestrian struck, unknown history, noncommunicative. Rule out
injury.
COMPARISON: None available.
TECHNIQUE: Axial helical MDCT images were obtained through the cervical spine
without IV contrast. Coronal and sagittal reformats were generated.
FINDINGS: There is a linear lucency extending throught the left hard palate
which is concerning for an acute fracture. There is a fracture at the right
occpitial condyle without significant displacement. Prevertebral thickening
is concerning for a ligamenotus injury. Multilevel degenerative changes are
noted with subchondral cysts, endplate sclerosis and anterior osteophytosis.
There is mucosal thickening of the left maxillary sinus.
IMPRESSION:
1. Left hard palate lucency concerning for a fracture. A dedicated facial
series would be helpful to further assess extent of injury.
2. Right occipital condyle fracture.
2. Prevertebral soft tissue thickening raises concern for an underlying
ligamentous injury. MR is recommended to further assess.
Initial findings discussed with Dr. ___ (neurosurgery),
by ___ in person on ___ at 9:01 AM, time of discovery.
Additional findings regarding fractures discussed via telephone with ___
___ by ___ at 9:30 AM. Prevertebral thickening finding discussed with
Dr. ___ by ___ via telephone on ___ at 10:05 AM.
Radiology Report
HISTORY: Pedestrian struck, unknown history, noncommunicative. Rule out
injury.
COMPARISON: None available.
TECHNIQUE: Axial helical MDCT images were obtained through the chest, abdomen
and pelvis after the uneventful administration of 130 cc of Omnipaque IV
contrast. Coronal and sagittal reformats were generated.
FINDINGS:
CT CHEST: There is no evidence of aortic traumatic injury. There is no
mediastinal hematoma. The great vessels are within normal limits. The heart
is normal in size. There is no pericardial effusion. Endotracheal tube is in
adequate position. There is atelectasis at the lung bases bilaterally. No
pneumothorax or pleural effusion. Calcified pleural plaque noted at the
lateral and medial aspect of the right lung as well as the left lung base.
There is a small hiatal hernia.
CT OF THE ABDOMEN: The liver, gallbladder, pancreas and adrenal glands are
normal. The portal vein is patent. The spleen is within normal limits. The
kidneys enhance symmetrically and excrete contrast with no evidence of
hydronephrosis or masses.
Stomach is within normal limits. There is no bowel obstruction or bowel wall
abnormality. There is no mesenteric contusion. The aorta is of normal
caliber. The celiac axis, SMA, bilateral renal arteries and ___ are patent.
There is no free air or free fluid.
CT OF THE PELVIS: The urinary bladder and terminal ureters are within normal
limits. The prostate is normal. There is no pelvic free fluid. There is no
pelvic or inguinal lymphadenopathy.
OSSESOUS STRUCTURES: Subtle fragmentation of the right transverse processes
at L1 is likely chronic. Clinical correlation is recommended. Otherwise, no
lytic or blastic lesions concerning for malignancy.
IMPRESSION:
1. Subtle fragmentation of the right transverse processes at L1 is likely
chronic. Clinical correlation for focal pain is recommended.
2. Bibasilar atelectasis.
3. No acute intra-abdominal or pelvic injury.
Findings discussed with Dr. ___ by ___ in
person on ___ at 9:01 AM, time of discovery and subsequently with
Dr. ___ telephone at 10:00 AM.
Radiology Report
HISTORY: ___ male with facial trauma, frontal bone fracture.
COMPARISON: Prior head CT and cervical spine CT from ___.
TECHNIQUE: Axial helical MDCT images were obtained through the facial bones
and sinuses without IV contrast. Coronal and sagittal reformats were
generated.
FINDINGS: A frontal bone fracture line extends through the left frontal sinus,
the posterior table of the skull and through the left maxillary sinus (2:3,
18, 21, 44), contiguous with a fracture identified in the left hard palate.
There is no evidence of pneumocephalus. There is near complete opacification
of the left frontal sinus. There is mucosal thickening of the right frontal
sinus, ethmoidal air cells and right sphenoid sinus. The mandible and
pterygoids are intact. There is a small left superior orbital extraconal
hematoma. There is left sided propotosis. Deformities of the nasal bones
could represent an acute fracture. There is a right occipital condyle
fracture. Periapical lucencies may be related to an infectious process.
IMPRESSION:
1. Frontal bone fracture extending through the left frontal sinus, left
maxillary sinus and contiguous with a left hard palate fracture line. No
pneumocephalus.
2. Left superior orbital extraconal hematoma and left-sided proptosis.
3. Right occipital condyle fracture.
Radiology Report
CERVICAL SPINE MRI WITHOUT CONTRAST, ___
INDICATION: ___ man struck by a motor vehicle with a prevertebral
cervical edema on cervical spine CT. Assess for ligamentous injury.
COMPARISON: Cervical spine CT performed earlier on the same day.
TECHNIQUE: Sagittal T1-weighted, T2-weighted, and fat-suppressed T2-weighted
images of the cervical spine, with axial gradient echo images.
FINDINGS: There is bone marrow edema in the right occipital condyle related
to the fracture demonstrated on the preceding CT scan (3:12). There is bone
marrow edema along the superior endplate of the T4 vertebral body, without
associated deformity or loss of height, which may indicate a bone contusion or
a non-displaced fracture (3:8). Questionable linear lucencies parallel to the
superior endplates of T4 and T5 vertebral bodies, without loss of height, as
seen on the torso CT performed earlier on the same day. No bone marrow edema
is seen in the cervical vertebrae.
There is prevertebral edema from the craniocervical junction through C5-6.
There is edema in the anterior longitudinal ligament from C2-3 through C5-6,
and edema in the posterior longitudinal ligament from C1-2 through C2-3
levels. There is no evidence for ligamentous disruption, or intervertebral
disc disruption. There is edema in the interspinous ligaments from the
craniocervical junction through C6-7, as well as edema in the paravertebral
muscles of the cervical spine and suboccipital muscles. There is no evidence
for an epidural collection.
At C2-3, there is mild right neural foraminal narrowing by facet osteophytes.
At C3-4, there is a central disc osteophyte complex which indents the ventral
spinal cord and flattens its ventral surface, with moderate spinal canal
narrowing. There is high T2 signal within the cord at this level spanning 13
mm craniocaudad, compatible with edema or myelomalacia. Gradient echo images
demonstrate no evidence of blood products within the spinal cord at this
level. There is also mild bilateral neural foraminal narrowing by
uncovertebral osteophytes.
At C4-5, there is a left paracentral disc osteophyte complex which abuts the
ventral surface of the spinal cord on the left, with mild flattening but no
edema. There is mild to moderate associated spinal canal narrowing. There is
mild bilateral neural foraminal narrowing by uncovertebral osteophytes.
At C5-6, there is a small central disc osteophyte complex which mildly narrows
the spinal canal but does not deform the spinal cord. There is mild right and
moderate left neural foraminal narrowing by uncovertebral osteophytes.
At C6-7, no significant spinal canal or neural foraminal narrowing is seen.
At C7-T1, no significant spinal canal narrowing is seen.
At T1-2, there is an oval 12 x 9 x 6 mm fluid-intensity structure extending
from the distal left neural foramen into the extraforaminal soft tissues.
This could represent a nerve root sleeve diverticulum, but traumatic avulsion
of the root cannot be excluded.
Cerebellar tonsils are normally positioned. Imaged portion of the posterior
fossa is grossly unremarkable; this study is not technically optimized for its
evaluation. Mucosal thickening is noted in the imaged portions of the
maxillary sinuses. Known fractures through the left maxillary sinus and left
hard palate are not well demonstrated on this exam.
IMPRESSION:
1. Prevertebral edema in the upper cervical spine with edema of the anterior
longitudinal ligament from C2-3 through C5-6, and edema of the posterior
longitudinal ligament from C1-2 through C3-4. Interspinous ligament edema
from the craniocervical junction through C6-7, with adjacent posterior
paravertebral and suboccipital muscle edema.
2. Acute spinal cord edema versus chronic myelomalacia at C3-4, where the
spinal cord is deformed by a disc osteophyte complex which results in moderate
spinal canal stenosis.
3. 12 mm oval fluid-intensity structure in the distal left T1-2 neural
foramen and extraforaminal space, which may represent a nerve root sleeve
diverticulum, but traumatic avulsion of the T1 nerve root cannot be excluded.
Please correlate clinically.
4. Bone marrow edema along the superior endplate of the T4 vertebral body
without loss of height, which may indicate a bone contusion or a non-displaced
fracture. Bone marrow edema along the known right occipital condyle fracture.
Radiology Report
HISTORY: ___ male status post trauma, intubation, and orogastric tube
placement.
TECHNIQUE: Single frontal chest radiograph was obtained portably with the
patient in a semi upright position.
COMPARISON: ___ at approximately 7:30 a.m.
FINDINGS:
Endotracheal tube tip terminates approximately 6 cm above the carina. There
has been interval placement of an orogastric tube, which courses into the left
upper quadrant with tip out of view. No focal consolidation, pleural
effusion, pneumothorax, or pulmonary edema is detected. Heart and mediastinal
contours are within normal limits. Large pleural calcification along the
right lateral hemithorax is again noted.
IMPRESSION:
Satisfactory orogastric tube placement.
Interval retraction of the endotracheal tube from 3 to 6 cm above the carina.
This change was reported to ___ by ___ by phone at
4:02 p.m. on ___.
Radiology Report
RIGHT SHOULDER
INDICATION: Status post motor vehicle accident.
FINDINGS: Two projections performed as a portable radiograph are provided.
The assessment is limited. The right humeral head is in correct position. On
the current images, there is no convincing evidence of a fracture at the level
of the right shoulder. Again documented are known rib fractures, as seen on a
CT torso examination from ___ with multiple rib fractures and
pleural calcifications.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: PED STRUCK
Diagnosed with CLOSED SKULL VAULT FX, CLOS SKULL BASE FRACTURE, FX FACIAL BONE NEC-CLOSE, MV COLL W PEDEST-PEDEST, OPEN WOUND OF FOREHEAD
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: nan | Patient presented to ___ after being struck by a motor
vehicle. He was intuabted in the emergency department upon
arrival. Imaging with CT scan of the head and neck showed a left
frontal bone fracture that was nondisplaced as well as a
occipital condyle fracture. he was placed in a hard cervical
collar for the condyle fracture. He underwent MRI of the
cervical spine to assess for ligamentous or cord injury. the MRI
showed ligmentaous injury of the ALL and PLL as well as a
contusion of the cord at C3-4. he remained ___ hard collar and
discussion was had regaridng possible surgical intervention for
stabilization. On ___ he was trasnferred to the neurosurgery
service given no other injuries requiring care. He was on
decadron 4mg q8hours. On ___ his exam was improving as he was
antigravity with all 4 extremities with good strength. Surgery
for psoterior decompression and stabilization was tentatively
scheduled for ___.
On ___, upon discussion with Dr. ___ decided
on conservative treatment. He remains in hard collar at all
times. ___ was consulted and his diet was advanced.
On ___, ___ worked with patient and initially recommended
home with ___ but on re-evaluation today decided patient is not
strong enough for home and recommended rehab. The family,
however, had difficulty with their insurance and opted to rehab
the patient at home.
On ___ the patient was discharged to home with services in
stable condition. |
Name: ___ ___: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
___ Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Chest, abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with PMHx HTN and recent admission for pyogenic liver
abscess
on IV CTX/flagyl who presents with RUQ pain and pleuritic chest
pain.
Pt endorses worsening RUQ abdominal/flank/back pain since last
admission. Endorses subjective fevers, malaise. Also notes pain
in proximal thigh bilaterally and pleuritic chest pain with deep
inspiration. States that since discharge from previous
hospitalization, pt has been laying in bed most of the day.
Of note, had recent hospitalization at ___ ___, found
to have a pyogenic liver abscess. The abscess was unable to be
drained by ___, several biopsies were taken, gram stain showed ___
polys or microorganisms, tissue culture without growth. Pt was
treated with empiric flagyl and vanc/zosyn --> cefepime, and
discharged on IV CTX/flagyl for planned course of ___ weeks
pending surveillance imaging. Also had productive cough and CXR
with consolidation c/f possible HAP, and was treated with above
abx. Additionally, had type II NSTEMI and likely stress
cardiomyopathy at OSH with repeat TTE showing recovered LVEF 65%
from 35%.
In the ED:
- Initial vital signs: T 98, HR 107, BP 98/75, RR 16, O2 95% RA
Had desaturation to 88% on RA, placed on 2L NC and stable O2
- Exam notable for: well-appearing, TTP in RUQ, CTAB, RRR, ___
murmur, non-tender chest wall, ___ JVD
- Labs were notable for: WBC 9.1, Hgb 10, Plt 234, Na 139, K
3.9,
BUN/Cr ___, LFTs wnl, Lactate 1.4
- Studies performed include:
-- UA: few bacteria, trace leuk, neg nitrite, 3 WBC, 30 protein
-- CXR: left PICC terminating in left axillary vein, low lung
volumes with persistent right hemidiaphragmatic elevation,
presumed bibasilar patchy atelectasis
-- CT A/P w con: PE in RLL posterior and lateral basal segments,
patchy peripheral consolidation in posterior/lateral/anterior
basal RLL could represent infarction v pna v aspiration.
Occlusive thrombus from left common iliac vein to at least the
left femoral vein. Occlusive thrombus extending from right
femoral vein and distally. Interval decrease in size of known
right hepatic lobe abscess currently measuring 4.5 x 3.5 x 3.6
cm.
-- Bl ___ Dopplers (prelim): extensive bilateral deep vein
thrombosis
- Patient was given: Heparin gtt, CTX/flagyl, 2L IVF, Morphine,
Zofran
___ 20:11 IV Morphine Sulfate 4 mg
___ 20:11 IV Ceftriaxone 2 gm
___ 20:11 IV Ondansetron 4 mg
___ 20:11 IVF NS at 150 mL/hr
___ 22:13 IV MetroNIDAZOLE 500 mg
___ 22:13 IV Morphine Sulfate 4 mg
___ 02:18 IVF LR at 125 mL/hr
___ 02:43 IV Heparin 6100 UNIT
___ 02:43 IV Heparin at 1350 units/hr
___ 05:05 IV Alteplase 1mg/2mL (Clearance ie. PICC)
___ 07:42 IV Morphine Sulfate 2 mg
___ 09:46 IV Morphine Sulfate 2 mg
___ 10:30 IV MetroNIDAZOLE 500 mg
___ 13:12 IV Morphine Sulfate 4 mg
- Consults: Vascular Medicine
Vitals on transfer: T 99.2, HR 97, BP 131/87, RR 18, O2 98% RA
Upon arrival to the floor, pt endorses above history however is
sleepy and slow to answer questions. Endorses right sided
abdominal/flank/back pain with deep breaths, states pain is
severe, may have been relieved by morphine in ED. Endorses mild
dizziness, bl hip pain as well as mild dysuria and urinary
urgency. Otherwise denies ha, lh, LOC, cp, palp, sob or doe, abd
pain in other locations, diarrhea/constipation, n/v,
BRBPR/melena, hematuria.
Past Medical History:
Hypertension
BPH
Hiatal hernia, Gastric ulcerations ___
NSTEMI, type II ___
Stress Cardiomyopathy, resolved
Anemia
Thyroid nodule
s/p b/l knee replacement
Social History:
___
Family History:
Son - deceased, car accident
Son - deceased, poisoned
2 Daughters healthy
___ family history of VTE, early MI, arrhythmia,
cardiomyopathies,
or sudden cardiac death.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS: T 98.6, BP 112/75, HR 93, RR 18, O2 94% 2L NC
GENERAL: In ___ acute distress. Sleepy, intermittently falling
asleep during conversation, slow to answer questions.
HEENT: NCAT. PERRL, EOMI. Sclera anicteric and without
injection.
MMM.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. ___
murmurs/rubs/gallops.
RESP: Clear to auscultation bilaterally. ___ wheezes, rhonchi or
rales. ___ increased work of breathing.
ABDOMEN: Normal bowels sounds, soft, mildly distended, TTP RUQ
and right flank. Otherwise non-tender to deep palpation.
MSK: ___ spinous process tenderness. ___ CVA tenderness.
EXT: Trace pitting edema of LLE, ___ edema RLE. ___ clubbing or
cyanosis. ___ calf/popliteal tenderness, ___ tenderness of bl
thighs. Pulses DP/Radial 2+ bilaterally.
SKIN: Warm. ___ rash.
NEUROLOGIC: CN2-12 intact. ___ strength in bl UE and bl hip
flexors. Unable to participate in remainder of neuro exam d/t
sleepiness. AOx3.
PSYCH: appropriate mood and affect, occasional inappropriate
response to questions, however able to redirect with repeat
questioning
DISCHARGE PHYSICAL EXAM:
GENERAL: In ___ acute distress, sitting in bed
HEENT: NCAT. PERRL, EOMI. Sclera anicteric and without
injection.
MMM.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. ___
murmurs/rubs/gallops, JVP~7cm
RESP: Clear to auscultation bilaterally. ___ wheezes, rhonchi or
rales. ___ increased work of breathing.
ABDOMEN: Normal bowels sounds, soft, mildly distended, mild TTP
RUQ
and right flank. Otherwise non-tender to deep palpation
MSK: ___ spinous process tenderness. ___ CVA tenderness
EXT: Trace pitting edema of LLE, ___ edema RLE. ___ clubbing or
cyanosis. ___ calf/popliteal tenderness, ___ tenderness of bl
thighs. Pulses DP/Radial 2+ bilaterally.
SKIN: Warm. ___ rash. ___ evident skin findings, swelling, or
deformity at liver biopsy site
NEUROLOGIC: CN2-12 intact. ___ strength in bl UE and bl hip
flexors. AOx3.
Pertinent Results:
ADMISSION LABS
=================
___ 11:25PM BLOOD WBC-9.1 RBC-3.10* Hgb-10.0* Hct-31.1*
MCV-100* MCH-32.3* MCHC-32.2 RDW-14.1 RDWSD-51.5* Plt ___
___ 11:25PM BLOOD Neuts-75.1* Lymphs-9.3* Monos-14.0*
Eos-0.7* Baso-0.3 Im ___ AbsNeut-6.82* AbsLymp-0.84*
AbsMono-1.27* AbsEos-0.06 AbsBaso-0.03
___ 10:20AM BLOOD ___ PTT-96.3* ___
___ 11:25PM BLOOD Glucose-108* UreaN-28* Creat-0.8 Na-139
K-3.9 Cl-98 HCO3-24 AnGap-17
___ 11:25PM BLOOD ALT-6 AST-17 AlkPhos-70 TotBili-0.4
___ 11:25PM BLOOD cTropnT-<0.01 proBNP-375*
___ 11:25PM BLOOD Albumin-3.0*
___ 08:57PM BLOOD Lactate-1.4
___ 08:52PM URINE Color-Red* Appear-Clear Sp ___
___ 08:52PM URINE Blood-NEG Nitrite-NEG Protein-30*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-TR*
___ 08:52PM URINE RBC-1 WBC-3 Bacteri-FEW* Yeast-NONE
Epi-<1 TransE-<1
___ 08:52PM URINE CastHy-5*
DISCHARGE LABS
==========================
___ 05:04AM BLOOD WBC-5.8 RBC-3.44* Hgb-11.0* Hct-34.9*
MCV-102* MCH-32.0 MCHC-31.5* RDW-14.1 RDWSD-52.9* Plt ___
___ 05:04AM BLOOD ___ PTT-35.3 ___
___ 05:04AM BLOOD Glucose-86 UreaN-12 Creat-0.7 Na-139
K-4.0 Cl-100 HCO3-25 AnGap-14
___ 05:04AM BLOOD ALT-6 AST-14 AlkPhos-70 TotBili-0.4
___ 05:04AM BLOOD Albumin-2.8* Calcium-7.5* Phos-2.5*
Mg-1.8
MICROBIOLOGY
==================
NGTD on discharge on ___ blood cultures
IMAGING
============
CT ABDOMEN/PELVIS WITH CONTRAST ___
1. Pulmonary embolism in the right lower lobe posterior and
lateral basal
segments. Patchy peripheral consolidation in the posterior and
lateral basal, as well as anterior basal right lower lobe, new
compared to ___, could represent infarction,
versus pneumonia or aspiration. Also new small right pleural
effusion.
2. Occlusive thrombus extending from the left common iliac vein
to at least left femoral vein and out of view. Occlusive
thrombus extending from the right femoral vein and distally out
of view.
3. Interval decrease in size of the known right hepatic lobe
abscess currently measuring 4.5 x 3.5 x 3.6 cm.
LOWER EXTREMITY DOPPLER ___
FINDINGS:
On the right side, there is extensive noncompressible occlusive
thrombus in the common femoral, femoral, popliteal veins,
posterior tibial and peroneal veins. Venous Doppler waveforms
are seen in the proximal right common femoral vein proximal to
the thrombus. Possible slow flow versus artifact is seen in the
right popliteal, however this may represent collateralization.
On the left side, there is extensive noncompressible occlusive
thrombus in the common femoral, femoral, popliteal veins, and
posterior tibial veins. The peroneal veins not well visualized
but likely thrombosed as well. Some flow is seen within the
left popliteal vein, without respiratory variability.
___ evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
Extensive bilateral lower extremity deep vein thrombosis.
CT ANGIOGRAM CHEST ___
1. Bilateral pulmonary emboli as detailed above. ___ CT
findings of right
heart strain.
2. Consolidation in the right lower lobe, which is in part
compatible with mild atelectasis. Heterogeneous enhancement
suggests superimposed infarction in the setting of pulmonary
emboli and/or infection.
3. Small right pleural effusion.
TRANSTHORACIC ECHOCARDIOGRAM ___
CONCLUSION:
There is normal regional left ventricular systolic function.
Overall left ventricular systolic function is normal. The
visually estimated left ventricular ejection fraction is 60-65%.
Dilated right ventricular
cavity with depressed and possible dyskinetic free wall motion.
Tricuspid annular plane systolic excursion (TAPSE) is depressed.
There is mild [1+] tricuspid regurgitation. There is mild
pulmonary artery systolic hypertension.
IMPRESSION: Follow-up study to assess ventricular function.
Suboptimal image quality. Base of the right ventricle not well
visualized but the mid-wall appears dyskinetic and the wall of
the right ventricular outflow tract is dilated to 4.7cm (normal
3.5cm). Mild pulmonary artery systolic
hypertension.
Compared with the prior TTE (images reviewed) of ___, the
findings are similar.
LIVER/GALLBLADDER ULTRASOUND ___
Limited examination due to patient positioning. Previously seen
heterogeneous lesion within liver segment V/VIII on CT abdomen
pelvis performed ___, compatible with
biopsy-proven abscess, is not well visualized sonographically.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. CefTRIAXone 2 gm IV Q24H
2. Docusate Sodium 100 mg PO BID
3. MetroNIDAZOLE 750 mg PO TID
4. Polyethylene Glycol 17 g PO BID
5. Senna 8.6 mg PO BID
6. Gabapentin 300 mg PO TID
7. Hydrochlorothiazide 25 mg PO DAILY
8. Omeprazole 20 mg PO BID
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H
2. ___ 10 mg PO BID Duration: 4 Days
3. ___ 5 mg PO BID
First dose ___ after completing ___ loading doses on
___
4. Lidocaine 5% Patch 1 PTCH TD QAM
5. OxyCODONE (Immediate Release) 10 mg PO BID:PRN BREAKTHROUGH
PAIN Duration: 3 Days
RX *oxycodone 10 mg 1 tablet(s) by mouth twice a day Disp #*6
Tablet Refills:*0
6. CefTRIAXone 2 gm IV Q24H
7. Docusate Sodium 100 mg PO BID
8. Gabapentin 300 mg PO TID
9. Hydrochlorothiazide 25 mg PO DAILY
10. MetroNIDAZOLE 750 mg PO TID
11. Omeprazole 20 mg PO BID
12. Polyethylene Glycol 17 g PO BID
13. Senna 8.6 mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
bilateral deep vein thrombosis
submassive pulmonary embolism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT ABD AND PELVIS WITH CONTRAST
INDICATION: Evaluate for change, known liver abscess, worsening pain and
fevers.
TECHNIQUE: Single phase contrast: MDCT axial images were acquired through the
abdomen and pelvis following intravenous contrast administration.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Stationary Acquisition 6.5 s, 0.5 cm; CTDIvol = 31.3 mGy (Body) DLP =
15.6 mGy-cm.
2) Spiral Acquisition 6.3 s, 49.6 cm; CTDIvol = 14.0 mGy (Body) DLP = 694.1
mGy-cm.
Total DLP (Body) = 710 mGy-cm.
COMPARISON: CT abdomen pelvis dated ___.
FINDINGS:
LOWER CHEST: There is right lower lobe posterior and lateral basal segmental
and subsegmental pulmonary embolism. In the setting, patchy peripheral
consolidation in the posterior, lateral, and anterior basal right lower lobe,
new compared to ___, is concerning for pulmonary infarct, versus
pneumonia or aspiration. There is a small right pleural effusion, new
compared to ___. the heart is enlarged. No clear CT evidence
for right heart strain. Coronary artery calcifications are noted.
ABDOMEN:
HEPATOBILIARY: Again seen is a 4.5 x 3.5 x 3.6 cm right hepatic lobe hepatic
abscess, previously measuring up to 7.0 x 5.5 x 0.1 cm. 2 unchanged punctate
left hepatic lobe hypodensities near the hepatic dome are too small to
characterize. The liver is otherwise normal in attenuation and morphology
throughout. There is no evidence of intrahepatic or extrahepatic biliary
dilatation. The gallbladder appears unremarkable.
PANCREAS: The pancreas demonstrates age-appropriate bulk. Distal pancreatic
duct in the head is top-normal in caliber at 3 mm. There is no peripancreatic
stranding.
SPLEEN: The spleen is normal in size and unremarkable in appearance.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There is no evidence of solid renal lesions or hydronephrosis. There is no
perinephric abnormality.
GASTROINTESTINAL: There is a small hiatal hernia. Small bowel loops
demonstrate normal caliber, wall thickness, and enhancement throughout. The
colon and rectum are within normal limits. The appendix is within normal
limits.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The prostate is mildly enlarged.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Moderate atherosclerotic
disease is noted.
There is occlusive thrombus in the proximal right femoral vein extending
distally out of view with surrounding stranding (series 601, image 23). There
is also occlusive thrombus extending from the left common iliac vein to
proximal femoral vein and out of view with surrounding stranding (series 601,
image 39 and 27).
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: There are left inguinal and left femoral hernias.
IMPRESSION:
1. Pulmonary embolism in the right lower lobe posterior and lateral basal
segments. Patchy peripheral consolidation in the posterior and lateral basal,
as well as anterior basal right lower lobe, new compared to ___,
could represent infarction, versus pneumonia or aspiration. Also new small
right pleural effusion.
2. Occlusive thrombus extending from the left common iliac vein to at least
left femoral vein and out of view. Occlusive thrombus extending from the
right femoral vein and distally out of view.
3. Interval decrease in size of the known right hepatic lobe abscess currently
measuring 4.5 x 3.5 x 3.6 cm.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 1:52 am, 2 minutes after discovery
of the findings.
Radiology Report
EXAMINATION: BILAT LOWER EXT VEINS
INDICATION: ___ year old man with DVTs found on the abdomen pelvis. // Please
eval extent of DVTs
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the bilateral lower extremity veins.
COMPARISON: Same-day CT abdomen and pelvis
FINDINGS:
On the right side, there is extensive noncompressible occlusive thrombus in
the common femoral, femoral, popliteal veins, posterior tibial and peroneal
veins.. Venous Doppler waveforms are seen in the proximal right common femoral
vein proximal to the thrombus. Possible slow flow versus artifact is seen in
the right popliteal, however this may represent collateralization.
On the left side, there is extensive noncompressible occlusive thrombus in the
common femoral, femoral, popliteal veins, and posterior tibial veins. The
peroneal veins not well visualized but likely thrombosed as well. Some flow
is seen within the left popliteal vein, without respiratory variability.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
Extensive bilateral lower extremity deep vein thrombosis.
Radiology Report
EXAMINATION: CTA CHEST WITH CONTRAST
INDICATION: ___ year old man with extensive bl DVT, PE on CT A/P in RLL // PE
TECHNIQUE: Axial multidetector CT images were obtained through the thorax
after the uneventful administration of intravenous contrast. Reformatted
coronal, sagittal, thin slice axial images, and oblique maximal intensity
projection images were submitted to PACS and reviewed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 2.1 s, 27.6 cm; CTDIvol = 11.1 mGy (Body) DLP = 305.7
mGy-cm.
2) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 3.3 mGy (Body) DLP = 1.7
mGy-cm.
3) Stationary Acquisition 4.2 s, 0.5 cm; CTDIvol = 23.2 mGy (Body) DLP =
11.6 mGy-cm.
Total DLP (Body) = 319 mGy-cm.
COMPARISON: There are no comparison studies listed
FINDINGS:
HEART AND VASCULATURE: There are bilateral pulmonary emboli, including an
embolus which completely occludes the right middle lobe artery, an embolus
within the distal right interlobar artery extending to right lower lobe
segmental branches, and an embolus at the branch point of the left anterior
segmental artery. There is no right heart strain. There is mild dilatation
of the main pulmonary artery, measuring up to 3.2 cm, nonspecific but can be
seen in setting of underlying pulmonary hypertension.
There is mild atherosclerotic disease of the thoracic aorta with focal
outpouching of the aortic arch immediately distal to the left subclavian
artery which could represent a ductus diverticulum. There is no dissection or
intramural hematoma. Heart size is mildly enlarged. There is no flattening
of the interventricular septum to suggest right heart strain. No pericardial
effusion is seen.
AXILLA, HILA, AND MEDIASTINUM: No axillary, mediastinal, or hilar
lymphadenopathy is present. No mediastinal mass.
PLEURAL SPACES: Small right pleural effusion. No left pleural effusion. No
pneumothorax.
LUNGS/AIRWAYS: There is consolidation in the right lower lobe, which is in
part compatible with mild atelectasis. Heterogeneous enhancement suggests
superimposed infarction in the setting of pulmonary emboli and/or infection.
There is mild subsegmental atelectasis in the left lower lobe. There is no
evidence of mass or suspicious nodules in the aerated lungs.
Central airways are patent. There is collapse of subsegmental airways in the
right lower lobe..
BASE OF NECK: Visualized portions of the base of the neck are unremarkable.
ABDOMEN: Included portion of the upper abdomen is unremarkable. There is a
small hiatal hernia.
BONES: No suspicious osseous abnormality is seen.? There is no acute fracture.
IMPRESSION:
1. Bilateral pulmonary emboli as detailed above. No CT findings of right
heart strain.
2. Consolidation in the right lower lobe, which is in part compatible with
mild atelectasis. Heterogeneous enhancement suggests superimposed infarction
in the setting of pulmonary emboli and/or infection.
3. Small right pleural effusion.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT
INDICATION: ___ with PMHx HTN and recent admission for pyogenic liver abscess
on IV CTX/flagyl who presents with worsening RUQ pain and pleuritic chest
pain, found to have extensive bl proximal DVTs and submassive subsegmental PE
on CTA. Continuing to have severe RUQ pain and focal tenderness // Evaluate
for evidence of hematoma, abscess,
TECHNIQUE: Targeted gray scale and color Doppler ultrasound images of the
liver was obtained.
COMPARISON: CT abdomen pelvis performed ___. Abdominal
ultrasound performed ___.
FINDINGS:
Examination is limited due to patient positioning. Within these confines:
Hepatic parenchyma appears within normal limits. The contour of the liver is
smooth. The previously seen heterogeneous lesion within liver segment V/VIII
on CT abdomen pelvis performed ___, compatible with
biopsy-proven abscess, is not well visualized sonographically. There is no
intrahepatic biliary ductal dilatation. There is no perihepatic ascites.
Limited views of the gallbladder are unremarkable.
IMPRESSION:
Limited examination due to patient positioning. Previously seen heterogeneous
lesion within liver segment V/VIII on CT abdomen pelvis performed ___, compatible with biopsy-proven abscess, is not well visualized
sonographically.
Gender: M
Race: BLACK/AFRICAN
Arrive by AMBULANCE
Chief complaint: RUQ abdominal pain
Diagnosed with Right upper quadrant pain
temperature: 98.0
heartrate: 107.0
resprate: 16.0
o2sat: 95.0
sbp: 98.0
dbp: 75.0
level of pain: 10
level of acuity: 3.0 | BRIEF HOSPITAL COURSE:
====================
___ with PMHx HTN and recent admission for pyogenic liver
abscess on IV CTX/flagyl who presented with worsening RUQ pain
and pleuritic chest pain, found to have extensive bilateral
proximal DVTs and a submassive subsegmental PE on CT A/P. He
remained hemodynamically stable throughout his hospital stay; he
was initially started on IV heparin and transitioned to ___
for treatment of provoked PE in setting of infection and recent
hospitalizations. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Fevers
Major Surgical or Invasive Procedure:
Transesophageal echocardiography ___
Peripherally inserted central catheter (PICC) placement
___
History of Present Illness:
HISTORY OF PRESENT ILLNESS:
Mr. ___ is a ___ year old M with a history of DM, ESRD on
HD, afib on coumadin, AVR, ___, CAD s/p CABG, ICD implanted for
Vtach presenting from dialysis with fever. Patient reports
feeling generally unwell for the past ___ days with fatigue,
malaise. He had one episode of loose stools, not black or
bloody, yesterday, but otherwise has no focal symptoms. Denies
headache, sore throat, chest pain, shortness of breath, cough,
abdominal pain, nausea, vomiting. He sometimes makes a very
small amount of urine, however denies dysuria. Denies rash. He
was admitted in ___ for an infection of his ICD pocket
which was treated and ICD was resited. Pt denies pain or
discomfort related to new ICD site. He presented to dialysis
this morning and was noted to be febrile. CBC and blood cultures
were drawn and he was given 1 g of Tylenol and sent to the ED.
He did not receive any dialysis.
In the ED, initial VS were 99.6 78 113/68 16 96% RA. Initial
labs were notable for K 7.4, BUN/Cr of 92/11.9, Na 131, Phos
6.8, CK 508, HCO3 17. EKG demonstrated NSR at 74, PR prolonged
at 274, QS wide at 140, QTc 456, TWI I/L with ___epression laterally. Pt received calcium gluconate and insulin
with D50. Pt was emergently dialyzed in the ED. Pt also
received Vancomycin 1.5g and Gentamicin 200mg for possible
Transfer VS were 99.0 109 139/70 16 100% Nasal Cannula.
On arrival to the floor, pt's VS ___ 105/60 18 95% on 2L.
Pt reports he feels febrile, but reports his nausea and
diarrhea are improved.
Past Medical History:
1. CARDIAC RISK FACTORS
- HTN
- HLD
- T2DM
2. CARDIAC HISTORY
- CAD/MI: ___ s/p CABG and PCI OM c/b VT and IABP for
hemodynamic instability
- Chronic dCHF (LVEF=40%)
- Thromboembolic CVA ___ d/t ASD (lost left eye sight)
- Atrial fibrillation
- Aortic Stenosis s/p AVR ___
- CAD s/p CABG on ___
- Vtach - episode ___ periMI, also ___ postop s/p
partial penectomy
- Atrial fibrillation
- Aortic Stenosis s/p mechnical AVR
- Chronic dCHF
3. OTHER PAST MEDICAL HISTORY
- ESRD ___ diabetic nephropathy) on HD ___
- Gangrenous penile ulcer s/p penectomy (___)
- Obesity
- Obstructive sleep apnea on CPAP
- Right pleural effusion s/p thoracotomy/pleurectomy in ___
- Pancreatitis ischemic infarct
- GERD
- Carpal tunnel syndrome
- Thromboembolic CVA ___ d/t ASD (lost left eye sight)
- Bilateral Cataracts
Social History:
___
Family History:
Father - DM, Mother - heart disease
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VS - ___ 105/60 18 95% on 2L
General: Diaphoretic appearing, lying in bed, no apparent
distress
HEENT: NCAT, PERRL, EOMI, OP clear
Neck: No thyromegaly
CV: S1 S2, mechanical, no murmurs
Lungs: crackles at bases bilaterally
Abdomen: Obese, non-tender, non-distended, hyperactive BS
GU: Deferred
Ext: Trace edema, no cyanosis or clubbing
Neuro: Moving all 4 extremities
Skin: AVF fistula on RUE bandaged c/d/i
DISCHARGE PHYSICAL EXAM:
========================
VS: Temp 97.1-98.1, HR 52-60, BP 90-102/50-73, RR 18, O2sat
97-100% (RA), FSG 84-139, Wt on ___ 110.3 kg (was 105.7
on ___
I/O: 210 IV/BRP
General: Well appearing, NAD
HEENT: EOMI, MMM.
CV: RRR, normal S1 and loud mechanical-sounding S2. No
murmurs, rubs, or gallops.
Lungs: No increased respiratory effort. Sparse crackles at the
bases bilaterally. No wheezes or rhonchi.
Abdomen: Obese, soft, non-tender, non-distended with normal
bowel sounds.
Ext: WWP. 2+ pitting edema to the mid-shin bilaterally.
Neuro: Awake and alert. Oriented to situation.
Pertinent Results:
ADMISSION LABS
==============
___ 09:52AM BLOOD WBC-10.6 RBC-3.56* Hgb-11.8* Hct-35.0*
MCV-98 MCH-33.0* MCHC-33.6 RDW-14.8 Plt ___
___ 09:52AM BLOOD Neuts-87.0* Lymphs-6.2* Monos-5.9 Eos-0.9
Baso-0.1
___ 09:52AM BLOOD ___ PTT-44.7* ___
___ 09:52AM BLOOD Glucose-78 UreaN-92* Creat-11.9*# Na-130*
K-8.4* Cl-93* HCO3-15* AnGap-30*
___ 12:00PM BLOOD CK(CPK)-508*
___ 12:00PM BLOOD CK-MB-6
___ 12:00PM BLOOD Calcium-8.6 Phos-6.8*# Mg-1.9
___ 10:04AM BLOOD Lactate-3.2* K-7.4*
PERTINENT INPATIENT LABS
========================
___ 07:05AM BLOOD WBC-11.5* RBC-3.43* Hgb-11.0* Hct-33.8*
MCV-99* MCH-32.2* MCHC-32.7 RDW-14.9 Plt ___
___ 04:16PM BLOOD ___ PTT-46.9* ___
___ 07:05AM BLOOD Glucose-91 UreaN-47* Creat-7.8*# Na-138
K-5.3* Cl-97 HCO3-27 AnGap-19
___ 07:05AM BLOOD Calcium-8.4 Phos-5.7* Mg-1.9
___ 07:23AM BLOOD WBC-8.0 RBC-3.24* Hgb-10.6* Hct-31.7*
MCV-98 MCH-32.8* MCHC-33.5 RDW-15.0 Plt ___
___ 07:23AM BLOOD ___
___ 07:23AM BLOOD Glucose-142* UreaN-66* Creat-9.4*#
Na-131* K-5.6* Cl-91* HCO3-24 AnGap-22
___ 07:23AM BLOOD Calcium-8.2* Phos-6.2* Mg-2.0
___ 08:10AM BLOOD WBC-8.2 RBC-3.48* Hgb-11.2* Hct-34.6*
MCV-99* MCH-32.2* MCHC-32.4 RDW-14.9 Plt ___
___ 08:10AM BLOOD ___ PTT-43.5* ___
___ 08:10AM BLOOD ESR-76*
___ 08:10AM BLOOD CRP-255.1*
___ 08:10AM BLOOD Glucose-101* UreaN-38* Creat-6.7*#
Na-131* K-4.7 Cl-89* HCO3-28 AnGap-19
___ 08:10AM BLOOD ALT-34 AST-53* LD(LDH)-281* AlkPhos-75
TotBili-0.7
___ 08:10AM BLOOD Albumin-3.6 Calcium-8.2* Phos-4.3# Mg-1.9
___ 06:50AM BLOOD ___ PTT-36.9* ___
___ 06:10AM BLOOD Glucose-122* UreaN-53* Creat-8.5*#
Na-129* K-4.5 Cl-88* HCO3-25 AnGap-21*
___ 06:10AM BLOOD Calcium-7.5* Phos-5.0* Mg-2.2
___ 06:10AM BLOOD Vanco-22.0*
___ 03:30PM BLOOD Genta-1.5*
___ 07:55AM BLOOD ___ PTT-35.5 ___
___ 11:52PM BLOOD ___ PTT->150* ___
___ 07:55AM BLOOD Glucose-103* UreaN-34* Creat-6.0*# Na-136
K-4.1 Cl-97 HCO3-31 AnGap-12
___ 07:55AM BLOOD Calcium-7.9* Phos-3.9 Mg-2.0
___ 07:55AM BLOOD Genta-1.5*
___ 06:00AM BLOOD ___ PTT-94.8* ___
___ 01:15PM BLOOD PTT-150*
___ 09:00PM BLOOD PTT-85.4*
___ 06:00AM BLOOD Glucose-99 UreaN-42* Creat-7.6*# Na-137
K-4.4 Cl-95* HCO3-24 AnGap-22*
___ 06:00AM BLOOD ALT-27 AST-33 LD(LDH)-264* AlkPhos-72
TotBili-0.3
___ 06:00AM BLOOD Albumin-3.5 Calcium-7.9* Phos-4.0 Mg-2.4
___ 07:15AM BLOOD WBC-6.2 RBC-3.27* Hgb-10.6* Hct-32.7*
MCV-100* MCH-32.4* MCHC-32.3 RDW-15.7* Plt ___
___ 02:52AM BLOOD ___ PTT-89.3* ___
___ 07:15AM BLOOD Glucose-108* UreaN-57* Creat-9.1*# Na-136
K-4.8 Cl-96 HCO3-24 AnGap-21*
___ 07:15AM BLOOD Calcium-8.0* Phos-5.7*# Mg-2.1
DISCHARGE LABS
==============
___ 07:20AM BLOOD WBC-4.6 RBC-3.21* Hgb-10.4* Hct-32.2*
MCV-100* MCH-32.3* MCHC-32.2 RDW-15.6* Plt ___
___ 07:20AM BLOOD ___ PTT-36.4 ___
___ 07:20AM BLOOD Glucose-107* UreaN-31* Creat-6.4*# Na-141
K-4.4 Cl-96 HCO3-29 AnGap-20
___ 07:20AM BLOOD Calcium-8.0* Phos-4.6* Mg-2.2
PERTINENT MICROBIOLOGY RESULTS
==============================
___ 6:00 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
ENTEROCOCCUS FAECALIS. FINAL SENSITIVITIES.
HIGH LEVEL GENTAMICIN SCREEN: Susceptible to 500 mcg/ml
of
gentamicin. Screen predicts possible synergy with
selected
penicillins or vancomycin. Consult ID for details.
HIGH LEVEL STREPTOMYCIN SCREEN: Susceptible to
1000mcg/ml of
streptomycin. Screen predicts possible synergy with
selected
penicillins or vancomycin. Consult ID for details..
Daptomycin 2 MCG/ML Sensitivity testing performed by
Etest.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS FAECALIS
|
AMPICILLIN------------ <=2 S
DAPTOMYCIN------------ S
PENICILLIN G---------- 2 S
VANCOMYCIN------------ 2 S
Anaerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN PAIRS AND CHAINS.
Reported to and read back by ___ ___
___.
Aerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN PAIRS AND CHAINS.
Blood cultures positive for Enterococcus faecalis on ___,
___
STUDIES:
========
TRANSESOPHAGEAL ECHOCARDIOGRAM (___)
The left atrium is dilated. The right atrium is dilated. No
atrial septal defect is seen by 2D or color Doppler. There is
mild symmetric left ventricular hypertrophy with normal cavity
size. Overall left ventricular systolic function is moderately
depressed (LVEF= ___ %). with moderate global free wall
hypokinesis. There are simple atheroma in the descending
thoracic aorta. A bileaflet aortic valve prosthesis is present.
The prosthetic aortic valve leaflets appear normal A mild
paravalvular aortic valve leak is present (best seen in the
short axis view at 5 o'clock, clips 48-50). No masses or
vegetations are seen on the aortic valve. No aortic valve
abscess is seen. The mitral valve leaflets are mildly thickened
with mild mitral regurgitation. No mass or vegetation is seen on
the mitral valve. There is no abscess of the tricuspid valve.
The pulmonary artery systolic pressure could not be determined.
No vegetation/mass is seen on the pulmonic valve. There is no
pericardial effusion.
IMPRESSION: No valvular vegetations or abscesses. Left
ventricular hypertrophy with normal cavity size and moderate
global systolic dysfunction. Moderate right ventricular systolic
dysfunction. Well seated mechanical aortic valve with mild
paravalvular leak. Simple atheroma in the thoracic aorta.
EKG ___: Sinus rhythm. P-R interval prolongation. Left
axis deviation. Intraventricular conduction delay. Since the
previous tracing of ___ the axis is now more leftward and
limb lead voltage is less prominent. Precordial ST-T wave
abnormalities are more prominent.
EKG ___: Normal sinus rhythm. One ventricular premature
complex. Diffuse non-specific ST-T wave abnormalities.
Non-specific intraventricular conduction delay. The P-R
interval is slightly prolonged at 220 milliseconds. Delayed R
wave progression in the precordial leads. Compared to the
previous tracing of ___ the P-R interval is shorter. The
premature ventricular complexes are new and the ST-T wave
abnormalities are slightly less marked but the Q-T interval is
longer.
PERTINENT INPATIENT IMAGING
===========================
Chest Radiograph, PA and Lateral (___):
FINDINGS: AP and lateral views of the chest. There is chronic
blunting of the right lateral costophrenic angle as on prior.
Lungs are clear of focal consolidation or effusion.
Cardiomediastinal silhouette is stable given differences in
positioning. Cutaneous ICD lead seen with lead in unchanged
position. Chronic deformities of the right posterior lateral
ribs again seen. No definite acute osseous abnormalities.
IMPRESSION: No definite acute cardiopulmonary process.
UNILAT UP EXT VEINS US RIGHT (___):
FINDINGS:
At the proximal fistula, there is possible thickening along the
posterior wall, possibly indicating a very small amount of
chronic mural thrombus. There is no intraluminal thrombus. The
fistula demonstrates good flow along the proximal, mid and
distal segments. There is no adjacent fluid collection.
IMPRESSION:
Mildly thickened proximal portion of the fistula, likely
secondary to more chronic mural thrombus; however, with good
flow seen throughout its proximal, mid and distal course. No
fluid collection identified.
CT ABD & PELVIS WITH CONTRAST (___):
IMPRESSION:
1. No evidence of acute intra-abdominal process. No discrete
fluid collection or abscess formation.
2. Atrophic kidneys compatible with history of end-stage renal
disease.
3. Extensive calcified atherosclerotic disease of the aorta and
its major branches without aneurysmal changes.
4. Slight thickening of the bladder wall, which may relate to
its underdistention. Clinical correlation is recommended.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Lidocaine-Prilocaine 1 Appl TP PRN apply over fistula 30
minutes prior to dialysis three times per week prior to dialysis
3. Omeprazole 40 mg PO BID
4. Pravastatin 80 mg PO HS
5. ammonium lactate 12 % topical daily
6. folic acid-B complex & C ___ mg oral DAILY
7. Metoprolol Succinate XL 50 mg PO DAILY
8. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q6H:PRN pain
9. Cinacalcet 30 mg PO DAILY
10. Docusate Sodium 100 mg PO BID
11. Warfarin 7 mg PO DAILY
12. sevelamer CARBONATE 800 mg PO TID W/MEALS
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Cinacalcet 30 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Lidocaine-Prilocaine 1 Appl TP PRN apply over fistula 30
minutes prior to dialysis three times per week prior to dialysis
5. Metoprolol Succinate XL 50 mg PO DAILY
6. Omeprazole 40 mg PO BID
7. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q6H:PRN pain
8. Pravastatin 80 mg PO HS
9. Ampicillin 2 g IV Q24H
RX *ampicillin sodium 2 gram 2 g IV once a day Disp #*37 Vial
Refills:*0
10. Gentamicin 80 mg IV ONCE Duration: 1 Dose
RX *gentamicin 20 mg/2 mL 8 mL IV after HD Disp #*64 Vial
Refills:*0
11. Warfarin 7 mg PO DAILY16
12. sevelamer CARBONATE 800 mg PO TID W/MEALS
13. ammonium lactate 12 % topical daily
14. folic acid-B complex & C ___ mg oral DAILY
15. Outpatient Lab Work
Please draw CBC with differential, BUN, Cr, ALT, AST, Alk phos,
Total bilirubin, ESR, CRP ___ while receiving IV
antibiotics
All laboratory results should be faxed to the ___
R.N.s at ___.
16. Outpatient Lab Work
Please draw Gentamicin level 2 hours post hemodialysis every
other ___
All laboratory results should be faxed to the ___
R.N.s at ___.
17. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line
flush
RX *sodium chloride 0.9 % [BD PosiFlush Normal Saline] 0.9 %
___ mL IV once a day Disp #*50 Syringe Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES:
# Enterococcal sepsis
# Hyperkalemia
# Polymorphic ventricular tachycardia
SECONDARY DIAGNOSES:
# End stage renal disease on hemodialysis
# Coronary artery disease
# Diabetes mellitus
# Obstructive sleep apnea
# Hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
CHEST, TWO VIEWS: ___
HISTORY: ___ male with fever and shortness of breath.
COMPARISON: ___.
FINDINGS: AP and lateral views of the chest. There is chronic blunting of
the right lateral costophrenic angle as on prior. Lungs are clear of focal
consolidation or effusion. Cardiomediastinal silhouette is stable given
differences in positioning. Cutaneous ICD lead seen with lead in unchanged
position. Chronic deformities of the right posterior lateral ribs again seen.
No definite acute osseous abnormalities.
IMPRESSION: No definite acute cardiopulmonary process.
Radiology Report
INDICATION: Patient with end-stage renal disease on hemodialysis, now with
bacteremia. Assess for intra-abdominal abscess formation or source of
infection.
COMPARISONS: CT pelvis of ___ and CT abdomen and pelvis of ___.
FINDINGS:
CT OF THE ABDOMEN:
The liver demonstrates homogeneous enhancement without suspicious focal
lesions. There is no evidence of intrahepatic or extrahepatic biliary ductal
dilatation. The portal vein is patent. The gallbladder is surgically absent.
CBD is of normal caliber measuring 6 mm. The spleen is normal in size. The
pancreas enhances homogeneously without ductal dilatation or peripancreatic
fluid collection. The adrenal glands are thickened without discrete
nodularity, unchanged. The kidneys appear atrophic, consistent with known
history of end-stage renal disease. There is lack of renal parenchymal
enhancement without hydronephrosis. Perirenal fat stranding is noted, which
is nonspecific in nature.
Small and large bowel loops are normal in caliber without evidence of bowel
wall thickening or obstruction. The appendix is visualized and is normal. No
discrete fluid collection is seen. No abscess formation. Diastasis of the
rectus abdominal muscles is noted. Mild periumbilical stranding is present.
Scattered mesenteric and retroperitoneal lymph nodes, which are not
pathologically enlarged. Intra-abdominal aorta and its major branches
demonstrate calcified atherosclerotic disease without aneurysmal changes.
The bladder is non-distended. There is mild bladder wall thickening, which
most likely relates to underdistension. The rectum and sigmoid colon are
unremarkable. There is no evidence of diverticulitis. Heavily calcified vas
deferens are noted bilaterally, which is often seen in the setting of
diabetes. Bilateral fat-containing inguinal hernia is present. There is no
inguinal or pelvic wall lymphadenopathy. Extensive iliac vessel
calcifications are noted.
OSSEOUS STRUCTURES: No suspicious lytic or sclerotic bony lesion is seen.
Right anterior rib deformity is stable, likely relates to prior trauma.
IMPRESSION:
1. No evidence of acute intra-abdominal process. No discrete fluid
collection or abscess formation.
2. Atrophic kidneys compatible with history of end-stage renal disease.
3. Extensive calcified atherosclerotic disease of the aorta and its major
branches without aneurysmal changes.
4. Slight thickening of the bladder wall, which may relate to its
underdistention. Clinical correlation is recommended.
Radiology Report
INDICATION: History of end-stage renal disease on hemodialysis, presenting
with enterococcus bacteremia. Please assess fistula for infected clot.
COMPARISONS: Fistulagram from ___.
TECHNIQUE: Focused ultrasound of the right fistula.
FINDINGS:
At the proximal fistula, there is possible thickening along the posterior
wall, possibly indicating a very small amount of chronic mural thrombus.
There is no intraluminal thrombus. The fistula demonstrates good flow along
the proximal, mid and distal segments. There is no adjacent fluid collection.
IMPRESSION:
Mildly thickened proximal portion of the fistula, likely secondary to more
chronic mural thrombus; however, with good flow seen throughout its proximal,
mid and distal course. No fluid collection identified.
Radiology Report
INDICATION: ___ year old man with new left PICC.
TECHNIQUE: Portable chest radiograph.
COMPARISON: Chest radiographs ___ through ___.
FINDINGS:
Interval placement of a left PICC which ends in the right atrium and can be
pulled back approximately 3-4 cm. There is no pneumothorax. The
cardiomediastinal and hilar contours are unchanged. The lungs are grossly
clear. There is no pleural effusion.
IMPRESSION:
New left PICC ends in the right atrium and can be pulled back approximately
3-4 cm.
NOTIFICATION: Findings were paged to ___ the IV nurse by Dr. ___ on ___ at 11:45, 40 minutes after they were made.
Radiology Report
EXAMINATION: CHEST PORT. LINE PLACEMENT
INDICATION: ___ year old man with new PICC // assess PICC placement Contact
name: ___: ___
TECHNIQUE: Portable chest radiograph
COMPARISON: ___.
FINDINGS:
The left PICC line is now at the junction of the superior vena cava and the
atrium. No other change.
IMPRESSION:
PICC line in correct position.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Fever, Diarrhea
Diagnosed with FEVER, UNSPECIFIED, HYPERKALEMIA, ABNORM ELECTROCARDIOGRAM, END STAGE RENAL DISEASE
temperature: 99.6
heartrate: 78.0
resprate: 16.0
o2sat: 96.0
sbp: 113.0
dbp: 68.0
level of pain: 3
level of acuity: 3.0 | ___ is a ___ year-old man with a history of ESRD on
HD, DM, CAD, atrial fibrillation on metoprolol and Coumadin,
ventricular tachycardia arrest s/p AICD placement and gangrenous
penile ulcer s/p distal penectomy admitted with fever and found
to have persistent enterococcus bacteremia treated with
ampicillin and gentamycin complicated by polymorphic ventricular
tachycardia with appropriate AICD therapy. |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Motrin / Bactrim / Compazine / tramadol
Attending: ___.
Chief Complaint:
abdominal pain, diarrhea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ female with the past medical history
noted below who presented to the ED w/ abdominal pain; diarrhea
and fever. History has been obtained by discussing w/ patient
and her daughter at the bedside and reviewing records.
Approximately ___ days back she started experiencing primarily
upper abdominal discomfort that was intermittent in nature w/out
any specific exacerbating or relieving factors. Progressively
worsened to involve right side of abdomen too and at times was
radiating to the back. At it worst, she rates it as ___ in
intensity.
Over the same period, she reports fever as high as ___ at home.
Shortly after the aforementioned symptoms started -- she dev.
profuse watery diarrhea - upto 12 times/day. Initially
non-bloody and then turned out to be admixed w/ bright red blood
and "dark blood". No vomiting but endorses dry heaves.
Her daughter finally convinced her to come to the hospital and
following arrival in the ED, after basic work-up, she was
referred for admission to Hospitalist service.
Patient has had 3 prior C. difficile infections -- most recent
___ for which she completed prolonged Vancomycin taper. At
some point, fecal microbiota transplant was considered but was
eventually deferred as she had no recurrence for several months.
In ___ this year she was treated again for presumptive C.
difficile infection (PCR+; tox neg). Denies recent Abx use with
the last month. Uses BID PPI for GERD.
Apart from this, she reports compliance w/ home meds -- except
that she ran out of Advair inhaler (asthma). Has chronic
heartburn. Intermittent ___ swelling. No chest pain. Feels weak
and reports shortness of breath at times. Non-compliant w/ CPAP.
Of note -- patient's daughter states that some family members w/
sick w/ nausea/diarrhea around the same time but they have since
recovered.
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
HTN
HLD
OSA - CPAP NON-COMPLIANT
DM
GERD
POSSIBLE CELIAC DZ
ASTHMA
SEASONAL ALLERGIES
DIASTOLIC CHF
DEPRESSION
Nephrolithiasis w/ mult. ESWL; stenting + stone extraction
Recurr. C.difficile infection
Hepatic steatosis
Social History:
___
Family History:
Mother: deceased - ___ Mellitus, Myocardial infarction
Father: deceased- ___ Cancer (dx at ___), Deep venous
thrombophlebitis
Sister: deceased ___ ___ Cancer (dx at ___)
Sister: ?IBD
Daughter: IBS
Physical Exam:
ADMISSION:
=========
VITALS: Afebrile and vital signs stable (see eFlowsheet)
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion - dry
CV: Heart regular, no murmur, no S3, no S4. No JVD.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, primarily epigastric ttp but no
guarding or rigidity. Bowel sounds present. No HSM
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: No rashes . Old tattoos -- RLE
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout
PSYCH: pleasant, appropriate affect
The patient was examined on the day of discharge.
Pertinent Results:
ADMISSION/SIGNIFICANT LABS:
========================
___ 08:53PM BLOOD WBC-8.5 RBC-4.66 Hgb-13.3 Hct-41.5 MCV-89
MCH-28.5 MCHC-32.0 RDW-14.5 RDWSD-46.6* Plt ___
___ 08:53PM BLOOD Neuts-50 ___ Monos-10 Eos-1 Baso-0
Atyps-3* Plasma-1* AbsNeut-4.25 AbsLymp-3.23 AbsMono-0.85*
AbsEos-0.09 AbsBaso-0.00*
___ 08:53PM BLOOD Glucose-112* UreaN-13 Creat-0.7 Na-141
K-4.6 Cl-98 HCO3-29 AnGap-14
___ 12:37AM BLOOD ALT-26 AST-23 AlkPhos-91 TotBili-0.2
___ 12:41AM BLOOD Lactate-1.7
MICRO:
=====
Cdiff PCR and toxin assay positive
IMAGING/OTHER STUDIES:
====================
CT a/p ___
IMPRESSION:
-Nonobstructing 8 mm stone in the right kidney.
-No acute findings in the abdomen and pelvis.
LABS ON DISCHARGE:
================
___ 07:20AM BLOOD WBC-7.7 RBC-4.15 Hgb-11.7 Hct-36.8 MCV-89
MCH-28.2 MCHC-31.8* RDW-14.2 RDWSD-46.3 Plt ___
___ 07:20AM BLOOD Glucose-116* UreaN-6 Creat-0.5 Na-144
K-4.1 Cl-103 HCO3-29 AnGap-12
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. DICYCLOMine 20 mg PO BID
2. Lisinopril 40 mg PO DAILY
3. Loratadine 10 mg PO DAILY
4. Metoprolol Succinate XL 150 mg PO DAILY
5. Pantoprazole 40 mg PO Q12H
6. Ondansetron 8 mg PO BID:PRN nausea
7. Pravastatin 80 mg PO QPM
8. Ranitidine 300 mg PO QHS
9. Sucralfate 1 gm PO TID:PRN EPIGASTRIC DISCOMFORT
10. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q4-6H:PRN
11. MetFORMIN (Glucophage) 500 mg PO BID
12. OxyCODONE--Acetaminophen (5mg-325mg) 1 TAB PO Q8H:PRN Pain -
Moderate
13. Furosemide 60 mg PO DAILY
14. AirDuo RespiClick (fluticasone propion-salmeterol) 232-14
mcg/actuation inhalation BID
15. LOPERamide 2 mg PO TID:PRN diarrhea
16. Montelukast 10 mg PO DAILY
Discharge Medications:
1. Vancomycin Oral Liquid ___ mg PO QID
RX *vancomycin [Vancocin] 125 mg 1 capsule(s) by mouth
asdirected in taper Disp #*68 Capsule Refills:*0
2. AirDuo RespiClick (fluticasone propion-salmeterol) 232-14
mcg/actuation inhalation BID
3. DICYCLOMine 20 mg PO BID
4. Lisinopril 40 mg PO DAILY
5. Loratadine 10 mg PO DAILY
6. MetFORMIN (Glucophage) 500 mg PO BID
7. Metoprolol Succinate XL 150 mg PO DAILY
8. Montelukast 10 mg PO DAILY
9. Ondansetron 8 mg PO BID:PRN nausea
10. OxyCODONE--Acetaminophen (5mg-325mg) 1 TAB PO Q8H:PRN Pain
- Moderate
11. Pantoprazole 40 mg PO Q12H
12. Pravastatin 80 mg PO QPM
13. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q4-6H:PRN
14. Ranitidine 300 mg PO QHS
15. Sucralfate 1 gm PO TID:PRN EPIGASTRIC DISCOMFORT
16. HELD- Furosemide 60 mg PO DAILY This medication was held.
Do not restart Furosemide until instructed by PCP or as per
detailed in discharge instructions.
17. HELD- LOPERamide 2 mg PO TID:PRN diarrhea This medication
was held. Do not restart LOPERamide until you complete treatment
for Cdiff colitis.
Discharge Disposition:
Home
Discharge Diagnosis:
# Recurrent CDI:
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: History: ___ with heart failure, hypoxemia// pna? chf?
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph from ___.
FINDINGS:
Low lung volumes with bibasilar atelectasis. There is no focal consolidation,
pleural effusion, or pneumothorax. Cardiomediastinal silhouette is within
normal limits.
IMPRESSION:
No focal consolidation or pulmonary edema.
Radiology Report
EXAMINATION: CT ABD AND PELVIS WITH CONTRAST
INDICATION: NO_PO contrast; History: ___ with fever, abdominal pain, bloody
stools. Evaluate for colitis.
TECHNIQUE: Single phase contrast: MDCT axial images were acquired through the
abdomen and pelvis following intravenous contrast administration.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Stationary Acquisition 6.0 s, 0.5 cm; CTDIvol = 28.9 mGy (Body) DLP =
14.4 mGy-cm.
2) Spiral Acquisition 6.9 s, 54.1 cm; CTDIvol = 27.5 mGy (Body) DLP =
1,484.9 mGy-cm.
Total DLP (Body) = 1,499 mGy-cm.
COMPARISON: CT of the abdomen from ___.
FINDINGS:
LOWER CHEST: Mild bibasilar atelectasis without consolidation or pleural
effusion. Moderate calcifications of the coronary arteries. No pericardial
effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous no attenuation throughout,
which may be associated steatosis. There is no evidence of focal lesions.
There is no evidence of intrahepatic or extrahepatic biliary dilatation. The
gallbladder is surgically absent.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal is mildly enlarged. No focal lesions are
identified.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: Several small hypodensities in the left kidney are too small to
characterize, may reflect cysts. Otherwise, the kidneys are of normal and
symmetric size with normal nephrogram. 8 mm stone is noted in the lower pole
of the right kidney (series 2, image 51). There is no evidence of focal renal
lesions or hydronephrosis. There is no perinephric abnormality.
GASTROINTESTINAL: A small hiatal hernia is noted. The stomach is
unremarkable. Small bowel loops demonstrate normal caliber, wall thickness,
and enhancement throughout. The colon and rectum are within normal limits.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The uterus is not visualized. No adnexal abnormality is
seen.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease
is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
-Nonobstructing 8 mm stone in the right kidney.
-No acute findings in the abdomen and pelvis.
Gender: F
Race: HISPANIC/LATINO - PUERTO RICAN
Arrive by AMBULANCE
Chief complaint: Fever, RUQ abdominal pain, Weakness
Diagnosed with Diarrhea, unspecified
temperature: 98.6
heartrate: 80.0
resprate: 18.0
o2sat: 94.0
sbp: 111.0
dbp: 71.0
level of pain: 8
level of acuity: 3.0 | Ms. ___ is a ___ female with PMH notable for recurrent
CDI, presents with abdominal pain, fever, and diarrhea, found to
have her fourth recurrence of C. Diff.
# Recurrent CDI:
Presented with crampy abdominal pain, fevers, and multiple loose
stools with PCR and toxin assay positive both positive for
C.difficile. No significant leukocytosis, ___, nor concerning
findings on CT (ie toxic megacolon). She did have small blood
associated with diarrhea but her hemoglobin remained normal
without acute anemia nor hemodynamic instability. Case discussed
with GI team given mention of Fecal Microbiota Transplant (FMT)
on prior admission, but determined patient did not meet criteria
for inpatient FMT at this time and instead recommended prolonged
taper of vancomycin with outpatient consideration of fecal
transplant. Her diarrhea was resolving and she was tolerating a
regular diet on the day of discharge. Follow up with PCP and GI
arranged.
Her Vancomycin taper on discharge is as follows:
125mg QID x 10d, then
BID x 7d, then
daily x 7d, then
QOD x14 days
# GIB:
Mild in setting of severe diarrhea. No associated H/H drop or HD
instability.
# Chronic dCHF:
Lasix held in setting of large volume diarrhea. No evidence of
acute exacerbation and patient euvolemic on discharge with a
weight of 100.61 kg, 221.8 lb. She was instructed to weigh
herself immediately once she got home and to resume her diuretic
if her weight increased > 2 lb or if she developed any new
leg/feet swelling.
# OSA/Asthma: - continued home bronchodilators.
# DM: - held home metformin initially. Resumed on discharge as
diarrhea was improving and renal function had remained stable.
TRANSITIONAL ISSUES:
=================
[] Ensure patient is compliant with prolonged taper of
Vancomycin for recurrent CDI.
[] If fails to improve, recommend FMT with GI
[] Monitor volume status as resumed lasix as clinically
indicated
[] discharge weight: 100.6 kg, 221.8 lb
> 30 mins spent coordinating discharge |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Keflex / Pyridium / amoxicillin / Penicillins / Neosporin
(neo-bac-polym) / Carbapenems
Attending: ___.
Chief Complaint:
blurry vision, feeling "off"
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ y/o female with a past medical
history of multiple myeloma currently C1D23
velcade/dexamethasone, history of HTN, CAD, allergies who
presented to the ED with fatigue, blurry vision and low grade
temp elevation. Patient was recently started on V/D and had a
reaction to zometa with severe eye inflammation for which she
was
seen by optho and started on eye drops. Her cycle 2 was delayed
because of this. She also has had worsening seasonal allergies
and was instructed to restart a prednisone taper, which she has
done in the past, is taking 10mg daily.
Regarding her vision blurriness was very sever over the past
week, she could see almost nothing from L eye, says that eye
doctor told her she was legally blind in that eye. was red but
not painful, no discharge or swelling. since starting drops she
has noticed ongoing improvement, still blurry but getting
better.
no double vision
Today she reports "feeling off" but has difficult time
describing further. says she felt foggy and just felt that
something was wrong. she took temp and was 99 which she reports
is high for her. when asked if she was confused says "yes
maybe".
no HA, no numbness or focal weakness. no nausea, ab pain or
diarrhea. she has been constipated since starting chemo, not
having adequate BM w/ senna/Colace just started miralax. she
denies any dysuria but has been urinating frequently. no flank
pain. does have some back pain in lower back that started
yesterday after episode of sneezing, not radiating, has improved
since yesterday but w/ certain movements she still has sharp
pains.
In the ED, T 98.4, BP 143/64, HR 85, 100% RA, RR 18. Labs were
notable for WBC 5.4, PMN 75%, Hb 9.6, PLT 377, Na 131, Ca 8.3,
lactate 1.2, UA negative however had few bacteria. Patient
received 1L NS and cipro 250 mg PO for presumed UTI. Vitals
prior
to transfer were T 98.2, HR 86, BP 140/76, RR 18, 100% RA.
Past Medical History:
PAST ONCOLOGIC HISTORY:
-Multiple myeloma, cycle 1 velcade/dex (day 1: ___ bony
lesions (right hip), monoclonal protein, new anemia and gross
proteinuria and BMBx that shows 80% plasma cell involvement
(IgG
Lambda).
-nephrotic range proteinuria s/p renal biopsy ___ with evidence
of light chain proximal tubulopathy
-Corneal abrasion
-Coronary artery disease (40% mid LAD, 20% ostial OM1,
___.
-OA
-HTN
-Zoster
-Asthma
-Environmental allergies
-HLD
-s/p CCY
Social History:
___
Family History:
Her father died at age ___ of an MI. Her mother died at age ___ of
colon cancer. She has one brother, one sister and no children.
Her brother has diabetes, hypertension, and hyperlipidemia. Her
sister has hypertension and hyperlipidemia. There is no family
history notable for stroke, early coronary artery disease or
sudden cardiac death.
Physical Exam:
Vitals: afeb, OVSS
Gen: Pleasant, calm
HEENT: No conjunctival pallor. No icterus. MMM. OP clear.
NECK: supple, no JVD, no LAD
CV: Normocardic, regular. Normal S1,S2. No MRG.
LUNGS: No incr WOB. CTAB. No wheezes, rales, or rhonchi.
ABD: NABS. Soft, NT, ND.
EXT: WWP. No ___ edema. mild ttp in L lower paraspinal region
SKIN: No rashes/lesions, petechiae/purpura ecchymoses.
NEURO: A&Ox3. L pupil dilated 4mm min reactive (pt was told by
opthal that eye will remain dilated into next week) EOMI, face
symmetric, no tongue deviation, no nystagmus. moves all ext
against resistance although R hip flexion difficult to sustain
due to arthritis in R hip. sensation intact to light touch.
visual fields full to confrontation bilat although unable to
read
clock or bulletin board across the room when closing R eye.
Pertinent Results:
___ 05:25AM BLOOD WBC-3.9* RBC-2.67* Hgb-8.8* Hct-27.8*
MCV-104* MCH-33.0* MCHC-31.7* RDW-13.7 RDWSD-52.5* Plt ___
___ 05:25AM BLOOD Glucose-106* UreaN-6 Creat-0.5 Na-137
K-4.1 Cl-105 HCO3-26 AnGap-10
___ 05:25AM BLOOD Calcium-8.6 Phos-3.1 Mg-2.1
CXR: No evidence of pneumonia.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 40 mg PO QPM
2. Fluticasone Propionate NASAL 2 SPRY NU DAILY
3. Montelukast 10 mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Acyclovir 400 mg PO Q8H
6. Lisinopril 20 mg PO DAILY
7. OxyCODONE (Immediate Release) ___ mg PO TID:PRN pain
8. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
9. Docusate Sodium 100-200 mg PO BID:PRN constipation
10. Senna 8.6-17.2 mg PO BID:PRN constipation
11. triamcinolone acetonide 55 mcg nasal daily prn congestion
12. Fluticasone Propionate 110mcg 2 PUFF IH DAILY
13. DiphenhydrAMINE ___ mg PO QHS:PRN sleep
14. Fexofenadine 60 mg PO DAILY
15. PredniSONE 10 mg PO DAILY
16. Polyethylene Glycol 17 g PO DAILY:PRN constipation
17. Acetaminophen ___ mg PO Q8H:PRN headache, mild pain
Discharge Medications:
1. Acetaminophen ___ mg PO Q8H:PRN headache, mild pain
2. Acyclovir 400 mg PO Q8H
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 40 mg PO QPM
5. DiphenhydrAMINE ___ mg PO QHS:PRN sleep
6. Docusate Sodium 100-200 mg PO BID:PRN constipation
7. Fexofenadine 60 mg PO DAILY
8. Fluticasone Propionate 110mcg 2 PUFF IH DAILY
9. Fluticasone Propionate NASAL 2 SPRY NU DAILY
10. Lisinopril 20 mg PO DAILY
11. Montelukast 10 mg PO DAILY
12. OxyCODONE (Immediate Release) ___ mg PO TID:PRN pain
13. Polyethylene Glycol 17 g PO DAILY:PRN constipation
14. PredniSONE 10 mg PO DAILY
15. Senna 8.6-17.2 mg PO BID:PRN constipation
16. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
17. triamcinolone acetonide 55 mcg nasal daily prn congestion
18. Tobramycin-Dexamethasone Ophth Oint 1 Appl LEFT EYE QHS
19. Cyclopentolate 1% 1 DROP LEFT EYE TID
20. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP LEFT EYE Q2 HR
Discharge Disposition:
Home
Discharge Diagnosis:
Multiple Myeloma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: Chest radiograph
INDICATION: ___ woman with multiple myeloma and fever, evaluate for
pneumonia.
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph ___.
FINDINGS:
Cardiomediastinal silhouette is stable. There is no pleural effusion or
pneumothorax. There is no focal lung consolidation. Biapical scarring is
stable.
IMPRESSION:
No evidence of pneumonia.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Fever
Diagnosed with Urinary tract infection, site not specified
temperature: 98.4
heartrate: 85.0
resprate: 18.0
o2sat: 100.0
sbp: 143.0
dbp: 64.0
level of pain: 0
level of acuity: 3.0 | Ms ___ is a ___ yr old female with hx multiple myeloma and
chronic severe allergies who was admitted with feeling "off" and
a mild temperature elevation.
Temperature elevation
- She had a mild temperature elevation to 99 at home. She had no
fevers while admitted and no focal findings for infection.
Multiple myeloma
- Currently C1D23 velcade/dex. most recent SPEP on ___ w/
improving IgG lambda levels. ca wnl and blood counts stable. C2
has been delayed due to zometa eye reaction. cont acv and
Bactrim prophy. She will follow up with her primary oncologist
as an outpatient.
L eye inflammation - ?uveitis, pt evaluated by outside
ophthalmologist, results of eye exam unknown. was presumed
effect
from zometa. cont on pred drops q2 hr while awake, cyclopentate
TID and tobradex oint qhs. She will follow up with her
ophthalmologist as an outpatient.
Back pain
- New since yesterday after sneezing. currently not requiring
pain medication (takes oxy only infrequently for her R hip
arthritis) on review of last bone scan pt has bony disease in
skull, femur and hips but not in vertebrae, did have
degenerative
disease. no spinal tenderness on exam. |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
lisinopril
Attending: ___
Chief Complaint:
Code Stroke
Major Surgical or Invasive Procedure:
tPA at 1710 on ___
History of Present Illness:
Reason for Consult: Code Stroke
Neurology at bedside for evaluation after code stroke activation
within: 1 minute
Time (and date) the patient was last known well: 16:00
___ Stroke Scale Score: 1
t-PA given: Already given
___ Total Score: 2
1a. Level of Consciousness: 0
1b. Month/Age: 0
1c. Follow Two Commands: 0
2. Best Gaze: 0
3. Visual Fields: 0
4. Facial Weakness: 1
5a. Left Arm Motor: 1
5b. Right Arm Motor: 0
6a. Left Leg Motor: 0
6b. Right Leg Motor: 0
7. Ataxia: 0
8. Sensory: 0
9. Language: 0
10. Dysarthria: 0
11. Extinction: 0
HISTORY OF PRESENT ILLNESS:
Mr. ___ is a ___ year old ___ man with a past medical
history
of afib s/p cardioversion, CAD, HTN, HLD, and DM who presents
today with sudden onset of left arm and face weakness.
He states that he was in his usual state of health, doing work
on
his patio. While doing this, all of a sudden he wasn't able to
move his left arm. He went to get his wife, had no leg weakness
or trouble walking. His wife noted that his arm was "dead" and
limp by his side, and that his face was also drooping on the
left. The patient is not sure if the arm was numb. She called
911
and he was brought to ___.
In the ___, ___ 5 for mild dysarthria, moderate facial
paresis, LUE drift and "borderline" LLE drift. ___
unremarkable
and he was given tPA at 17:10, and transferred to ___ ___.
En route, the patient stated that his symptoms improved. On
arrival he is able to move his left arm without issue, and his
wife says that his face looks much better. He notes that his
only
current problem is that his left hand is still very weak.
He has had a recent URI. Otherwise ROS negative.
He states that he was on pradaxa ___ years ago for one month
after cardioversion. He is no longer on it. There is some note
of
hematuria in the chart however patient denies this.
On neurologic review of systems, the patient denies headache,
loss of vision, blurred vision, diplopia, dysarthria, dysphagia,
lightheadedness, vertigo, tinnitus or hearing difficulty. Denies
difficulties producing or comprehending speech. No bowel or
bladder incontinence or retention. Denies difficulty with gait.
On general review of systems, the patient denies recent fever or
chills. No night sweats or recent weight loss or gain. Denies
cough, shortness of breath. Denies chest pain or tightness,
palpitations. Denies nausea, vomiting, diarrhea, constipation
or
abdominal pain. No recent change in bowel or bladder habits.
No
dysuria. Denies arthralgias or myalgias. Denies rash.
Past Medical History:
- Afib. s/p cardioversion ___, then on xarelto, stopped ___ for hematuria. Unclear if continued afib
- CAD (prior RCA stent, LAD stent ___
- HTN
- Ventricular bigeminy
- CKD stage III
- Type II DM
Social History:
___
Family History:
Unable to obtain - code stroke
Physical Exam:
Admission Exam:
Vitals: 76 144/87 14 97% RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple
Pulmonary: Lungs CTA bilaterally
Cardiac: irregular
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name ___ backward without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic errors.
Pt was able to name both high and low frequency objects. Able
to
read without difficulty. Speech was not dysarthric. Able to
follow both midline and appendicular commands. The pt had good
knowledge of current events. There was no evidence of apraxia or
neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: Left lower facial droop, mild.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. Slight pronation on the
left due to hand weakness but no drift. No adventitious
movements, such as tremor, noted. No asterixis noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ 0 0 0 5 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5 5
-Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout. No extinction to
DSS.
-DTRs:
___ Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was flexor bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally. FNF on left limited by
plegia of left hand, however no clear dysmetria on top of this.
-Gait: Deferred.
Discharge Exam: beginning to regain small amount of motion in
paretic hand.
Pertinent Results:
EKG ___:
" Heart Rate: 71
RR Interval: 845
QRSD Interval: 110
QT Interval: 390
QTC Interval: 424
QRS Axis: -8
T Wave Axis: 29
EKG Severity - ABNORMAL ECG -
EKG Impression: Atrial fibrillation
EKG Impression: Multiple ventricular
premature complexes
EKG Impression: Abnormal R-wave progression,
early transition"
OSH NCHCT:
FINDINGS: There is no evidence of infarction, hemorrhage, edema,
ormass. The ventricles and sulci are normal in size and
configuration. There is no evidence of fracture. There is mild
mucosal thickeningof the bilateral ethmoid air cells. The
visualized portion of the remain paranasal sinuses, mastoid air
cells, and middle ear
cavities are clear. The visualized portion of the orbits are
unremarkable.
IMPRESSION:
1. No intracranial hemorrhage or major territory acute
infarction.
___ TTE
The left atrium is elongated. No left atrial mass/thrombus seen
(best excluded by transesophageal echocardiography). The right
atrium is moderately dilated. No atrial septal defect is seen by
2D or color Doppler. There is mild symmetric left ventricular
hypertrophy with normal cavity size. There is mild regional left
ventricular systolic dysfunction with hypokinesis of the basal
inferior wall. There is very mild hypokinesis of the remaining
segments (LVEF = 50 %). There is considerable beat-to-beat
variability of the left ventricular ejection fraction due to an
irregular rhythm/premature beats. No masses or thrombi are seen
in the left ventricle. The right ventricular cavity is mildly
dilated with normal free wall contractility. The ascending aorta
is mildly dilated. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
stenosis or aortic regurgitation. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. Mild (1+)
mitral regurgitation is seen. There is borderline pulmonary
artery systolic hypertension. There is no pericardial effusion.
Compared with the prior study (images reviewed) of ___
the right ventricle is now mildly dilated. Focal hypokinesis of
the basal inferior wall is seen but was likley present before
(has old RCA stent). Other findings are similar.
___ MRI Brain, MRA head/neck
1. Acute infarction in the right precentral gyrus without
evidence of
hemorrhagic conversion.
2. Patent circle of ___.
3. Patent vasculature in the neck with no evidence of internal
carotid artery stenosis by NASCET criteria.
___ CT Head
1. No evidence of infarction. No evidence of hemorrhage.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atenolol 50 mg PO DAILY
2. Atorvastatin 40 mg PO QPM
3. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN angina
4. Aspirin 325 mg PO DAILY
5. Doxycycline Hyclate 50 mg PO EVERY OTHER DAY
Discharge Medications:
1. Atorvastatin 80 mg PO QPM
RX *atorvastatin 80 mg 1 tablet(s) by mouth before bed Disp #*30
Tablet Refills:*3
2. Doxycycline Hyclate 50 mg PO EVERY OTHER DAY
3. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN angina
4. Atenolol 25 mg PO DAILY
RX *atenolol 25 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*3
5. Apixaban 5 mg PO BID
RX *apixaban [Eliquis] 5 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*3
6. Outpatient Physical Therapy
ICD10 I63.4 Cerebral infarction due to embolism
Left hand weakness
Assess and treat
7. Outpatient Occupational Therapy
ICD10 I63.4 Cerebral infarction due to embolism
Left hand weakness
Assess and treat
Discharge Disposition:
Home
Discharge Diagnosis:
Embolic stroke
Atrial fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: MRI AND MRA BRAIN AND MRA NECK PT11 MR ___
INDICATION: ___ year old man with left face/hand weakness // eval for stroke
TECHNIQUE: Three dimensional time of flight MR arteriography was performed
through the brain with maximum intensity projection reconstructions.
Dynamic MRA of the neck was performed during administration of 20 mL of
Multihance intravenous contrast.
Brain imaging was performed with sagittal T1 and axial FLAIR, T2, gradient
echo and diffusion technique.
Three dimensional maximum intensity projection and segmented images were
generated. This report is based on interpretation of all of these images. The
examination was performed using a 1.5T MRI.
COMPARISON: CT head ___
FINDINGS:
MRI Brain:
Restricted diffusion in the right precentral gyrus is associated with T2/FLAIR
hyperintense signal. There is no evidence of hemorrhage, edema, masses, mass
effect, midline shift or infarction. The ventricles and sulci are normal in
caliber and configuration. Scattered foci of T2/FLAIR hyperintensities in the
periventricular and subcortical white matter are nonspecific, but may
represent the sequela of chronic small vessel ischemic disease.
There is mild mucosal thickening in the right maxillary sinus. The mastoid
air cells are clear. The orbits are unremarkable.
MRA brain: The intracranial vertebral and internal carotid arteries and their
major branches are patent without evidence of stenosis, occlusion, or aneurysm
formation.
MRA neck: There is a normal 3 vessel branching pattern of the aortic arch.
The common, internal and external carotid arteries are patent. There is no
evidence of internal carotid artery stenosis by NASCET criteria. The origins
of the great vessels, subclavian and vertebral arteries are patent
bilaterally.
IMPRESSION:
1. Acute infarction in the right precentral gyrus without evidence of
hemorrhagic conversion.
2. Patent circle of ___.
3. Patent vasculature in the neck with no evidence of internal carotid artery
stenosis by NASCET criteria.
NOTIFICATION: The findings were discussed with Dr. ___. by ___
___, M.D. on the telephone on ___ at 04:14 AM.
Radiology Report
EXAMINATION: Chest radiograph
INDICATION: ___ male with stroke. Evaluate for pulmonary infiltrate.
TECHNIQUE: Portable chest radiograph
COMPARISON: Chest radiograph ___
FINDINGS:
Lung volumes are normal. Streaky left lung base opacity likely represents
atelectasis. There is no other focal consolidation, pleural effusion or
pneumothorax. No pulmonary edema. Mild cardiomegaly. No subdiaphragmatic
free air. No acute osseous abnormalities identified.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD.
INDICATION: ___ year old man with l. stroke 24hr s/p TPA // ? CVA / bleeding.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 9.0 s, 15.3 cm; CTDIvol = 48.8 mGy (Head) DLP =
746.1 mGy-cm.
Total DLP (Head) = 761 mGy-cm.
COMPARISON: CT head ___.
FINDINGS:
There is no evidence of hemorrhage, edema, or mass. The ventricles and sulci
are normal in size and configuration.
There is no evidence of fracture. The visualized portion of the paranasal
sinuses, mastoid air cells, and middle ear cavities are clear. The visualized
portion of the orbits are unremarkable.
IMPRESSION:
1. No evidence of infarction. No evidence of hemorrhage.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: CVA, Transfer
Diagnosed with Cerebral infarction, unspecified, S/p admn tPA in diff fac w/n last 24 hr bef adm to crnt fac, Unspecified atrial fibrillation
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: Critical
level of acuity: 1.0 | Mr. ___ is a ___ year old ___ man with a past medical
history of afib s/p cardioversion, CAD, HTN, HLD, and DM who
presented with sudden onset of left arm and face weakness. He is
s/p tPA on ___ at 1710 and was admitted to the ICU for
post-tPA monitoring, did well, and was transferred to the floor
prior to discharge home.
.
#Neuro: after tPA, the patient had improving symptoms with
improved left arm strength but a left cortical hand. He was in
afib, so etiology is likely cardioembolic. MRI Brain confirmed
stroke in right frontal lobe in the primary motor cortex. He was
started on apixaban 5 BID. We increased Lipitor from 40mg to
80mg in an effort to better reduce the risk of recurrent stroke.
We decreased atenolol from 50 to 25mg daily because his blood
pressure was well controlled and the pulse was already quite low
on half the admission dose.
.
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? (x) Yes, confirmed
done - () Not confirmed () No
2. DVT Prophylaxis administered? (x) Yes - () No
3. Antithrombotic therapy administered by end of hospital day 2?
(x) Yes - () No
4. LDL documented? (x) Yes (LDL = 61) - () No
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 100) (x) Yes - () No [if
LDL >100, reason not given: ]
6. Smoking cessation counseling given? () Yes - (x) No [reason
(x) non-smoker - () unable to participate]
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (x) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
(x) Yes - () No
9. Discharged on statin therapy? (x) Yes - () No [if LDL >100,
reason not given: ]
10. Discharged on antithrombotic therapy? (x) Yes [Type: ()
Antiplatelet - (x) Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? (x) Yes - () No - () N/A |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___
Chief Complaint:
fevers
Major Surgical or Invasive Procedure:
none.
History of Present Illness:
Mr. ___ is a ___ with cryptogenic cirrhosis 8 months s/p
liver transplant ___, 1 month s/p R indirect hernia repair,
also recently admitted ___ for fevers, thought to be viral
in origin, GERD, esophageal dysmotility, DM on insulin
presenting from home with fevers/chills that started the night
prior to presentation. Pt reports having Tmax 101.3 at home;
reports having the chills and shaking, says that he couldn't
stop shivering. Also reports some associated fatigue and
malaise. No joint paint or muscle pain. He denies any recent
runny nose, sore throat, no recent sick contacts. No changes in
his bowel movements, no diarrhea, no n/v. He also denies any
chest pain, palpitations, no shortness of breath, no trouble
breathing. Denies any abdominal pain, no urinary symptoms.
.
Of note, the patient is immunosuppression for liver transplant,
including Rapamune 3.5 ___, Tacro 3 mg BID, and Myfortic 360
mg BID.
.
In the ED, initial vitals were 100.0 ___ 18 100% RA. Noted
to be febrile. Blood and urine cultures sent. UA without
evidence of infection. CXR. Patient diarrhea concerning for C.
Diff so sent for toxin. Blood counts near baseline. Creatinine
elevated at 3.0 with recent baseline 2.3. Potassium elevated to
6.2. EKG unchanged. Patient was given kayexalate 30mg and
regular insulin 10U IV. Vitals prior to transfer 98.1, Pulse:
89, RR: 18, BP: 120/64, O2Sat: 100%.
.
On arrival to the floor, the patient appeared comfortably, just
tired and wanting to sleep. He was complaining of some pain at
his IV site; was otherwise feeling well.
Past Medical History:
Hiatal hernia
GERD
esophageal dysmotility
prostate cancer s/p prostatectomy and penile prosthesis
depression
end-stage liver disease (liver cirrhosis) s/p transplant
diabetes on insulin
.
Past Surgical History:
___ Deceased donor liver transplant.
___ Exploratory laparotomy with removal of packs
liver biopsy and abdominal closure
prostatectomy
Social History:
___
Family History:
No family history of liver disease, diabetes, or premature CAD.
Physical Exam:
Admission PE:
Vitals: T 100.0 93/33 93 20 97 on RA
General: well appearing, pleasant elderly gentleman, NAD, laying
comfortably in bed
HEENT: sclera anicteric, mmm
Neck: supple, no LAD
Heart: RRR, S1, S2, no murmurs/rubs/gallops appreciated
Lungs: good air movement, clear to auscultation b/l, no
wheezes/rhonchi/crackles
Abdomen: soft, nontender, nondistended, well healed surgical
scar, + suprapubic mass (5cm), no tenderness to palpations (pt
says c/w penile implant)
Extremities: 2+ DP pules b/l, warm, well perfused extremities,
no ___ edema appreciated
Neurological: alert and oriented
.
Discharge PE:
Vitals: Tc 99.6 Tm 100 96/50 (93-125/33-64) 91 (85-105) 12 98 RA
850+ out/~2.3L in
General: well appearing, NAD, sitting up comfortably in chair
watching television
HEENT: sclera anicteric, mmm
Neck: supple, no LAD
Heart: RRR, S1, S2, no murmurs/rubs/gallops appreciated
Lungs: good air movement, clear to auscultation b/l, no
wheezes/rhonchi/crackles
Abdomen: soft, nontender, nondistended, well healed surgical
scar, + suprapubic mass (5cm), no tenderness to palpations (pt
says c/w penile implant)
Extremities: 2+ DP pules b/l, warm, well perfused extremities,
no ___ edema appreciated
Pertinent Results:
___ 10:10AM BLOOD WBC-5.2 RBC-3.04* Hgb-8.9* Hct-27.1*
MCV-89 MCH-29.1 MCHC-32.7 RDW-16.9* Plt ___
___ 06:30AM BLOOD WBC-5.5 RBC-2.90* Hgb-8.5* Hct-26.2*
MCV-91 MCH-29.3 MCHC-32.4 RDW-16.9* Plt ___
___ 06:30AM BLOOD ___
___ 10:10AM BLOOD Glucose-200* UreaN-55* Creat-3.0* Na-138
K-6.2* Cl-105 HCO3-24 AnGap-15
___ 05:10PM BLOOD Glucose-121* UreaN-45* Creat-2.5* Na-141
K-5.3* Cl-106 HCO3-26 AnGap-14
___ 06:30AM BLOOD Glucose-114* UreaN-39* Creat-2.4* Na-140
K-4.2 Cl-105 HCO3-24 AnGap-15
___ 10:10AM BLOOD ALT-47* AST-38 AlkPhos-189* TotBili-0.2
___ 06:30AM BLOOD ALT-47* AST-37 AlkPhos-177* TotBili-0.2
___ 05:10PM BLOOD Calcium-9.7 Phos-3.3 Mg-2.1
___ 06:30AM BLOOD Albumin-4.0 Calcium-9.3 Phos-3.1 Mg-1.9
Medications on Admission:
Lasix 40 mg ___
metoprolol tartrate 12.5 mg ___ BID
lansoprazole 30 mg ___
fenofibrate 54 mg ___
insulin lispro ISS
mirtazapine 30 mg ___ HS
Myfortic 360 mg ___ BID
sulfamethoxazole-trimethoprim 400-80 mg ___
tacrolimus 3 mg BID
Sirolimus 3.5 mg qday
tramadol 50 mg ___ Q6H PRN pain
ursodiol 300 mg BID
ferrous sulfate 300 mg (60 mg iron) TID
MVI
acetaminophen 650 q6H pain
Colace 100 mg BID
Discharge Medications:
1. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet ___ BID (2
times a day).
2. lansoprazole 30 mg Tablet,Rapid Dissolve, ___ Sig: One (1)
Tablet,Rapid Dissolve, ___ ___.
3. mirtazapine 30 mg Tablet Sig: One (1) Tablet ___ HS (at
bedtime).
4. mycophenolate sodium 180 mg Tablet, Delayed Release (E.C.)
Sig: Two (2) Tablet, Delayed Release (E.C.) ___ BID (2 times a
day).
5. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet ___.
6. ursodiol 300 mg Capsule Sig: One (1) Capsule ___ BID (2 times
a day).
7. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet ___ TID (3 times a day).
8. multivitamin Tablet Sig: One (1) Tablet ___.
9. docusate sodium 100 mg Capsule Sig: One (1) Capsule ___ BID (2
times a day).
10. acetaminophen 325 mg Tablet Sig: One (1) Tablet ___ Q6H
(every 6 hours) as needed for pain/fever.
11. tramadol 50 mg Tablet Sig: One (1) Tablet ___ Q6H (every 6
hours) as needed for pain.
12. insulin lispro 100 unit/mL Solution Sig: as directed
Subcutaneous as directed: please take insulin according to your
sliding scale.
13. sirolimus 1 mg Tablet Sig: Four (4) Tablet ___ once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
fever secondary to viral infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ man status post liver transplant, now with fevers and
chills.
COMPARISON: Multiple chest radiographs, the latest from ___.
TWO VIEWS OF THE CHEST: The lungs are well expanded and clear. The
cardiomediastinal silhouette, hilar contours, and pleural surfaces are normal.
No pleural effusion or pneumothorax is present.
IMPRESSION: No acute intrathoracic process.
Gender: M
Race: PORTUGUESE
Arrive by WALK IN
Chief complaint: FEVER/CHILLS
Diagnosed with FEVER, UNSPECIFIED, ACUTE KIDNEY FAILURE, UNSPECIFIED, LIVER TRANSPLANT STATUS
temperature: 100.0
heartrate: 109.0
resprate: 18.0
o2sat: 100.0
sbp: 99.0
dbp: 51.0
level of pain: 9
level of acuity: 3.0 | Mr. ___ is a ___ with cryptogenic cirrhosis 8 months s/p
liver transplant ___, 1 month s/p R indirect hernia repair,
also recently admitted ___ for fevers, thought to be viral
in origin, presenting from home with fevers/chills. No other
localizing symptoms.
.
# fevers: The patient reports having fevers at home, but was
afebrile while in patient. Besides fatigue, no other localizing
symptoms and his exam was also unremarkable. An infectious
work-up was negative, including blood and urine cultures with no
growth to date, negative Cdiff toxin, and normal CXR. The
patient is s/p hernia repair one month ago, and has hardware
(penile implant), but abdominal exam was benign. No antibiotics
were started, and fever curve was followed. Likely viral
etiology; the patient was also placed on precautions for rule
out influenza, but a nasopharyngeal swab was never attained, as
the patient could not tolerate it. On discharge from the
hospital, the patient reports feeling well and is afebrile.
.
# hyperkalemia: The patient was found to be hyperkalemic on
presentation with ED, with potassium of 6.2. Per report EKG was
normal and potassium normalized after kayexolate, with K+ on
discharge 4.2. Possibly related to tacrolimus or bactrim ppx.
Upon discharge, the patient's tacrolimus was stopped, and he was
just continued on sirolimus (see below).
.
# acute on chronic renal failure: The patient's normal baseline
is ~1.6, with creat at the end of ___. On admission,
had creat of 3.0. Likely related to being prerenal, secondary
to decreased ___ intake in the setting of infection; pt also
appeared dry on exam. Could also be related to tacrolimus
toxicity. Fluids were started after which the patient's creat
began to trend down, and tacrolimus levels were normal. On
discharge from hospital, creat had been trending down to 2.4.
At discharge, the patient's Lasix was also held. He will follow
up with transplant clinic.
.
# s/p liver transplant/immunosuppresion: The patient is s/p OLT
in ___. His sirolimus was stopped in early ___ prior to
his hernia repair surgery (sirolimus impairs wound healing) and
he was continued on tacrolimus and myfortic for
immunosuppression. On ___, the patient was restarted on
his sirolimus at 3.5 mg ___, and continued on tacrolimus 3 mg
BID until his sirolimus level was therapeutic. On the day of
discharge, his sirolimus level was 6.7 and it was decided to
increase his sirolimus to 4 mg ___ and stop his tacrolimus.
On discharge, the patient is on sirolimus 4 mg ___, and
Myfortic 360 mg BID. He was also continued on his Bactrim ppx,
and ursodiol 300 mg BID. His Lasix was held while in patient
given his likely prerenal etiology for acute on chronic renal
failure.
.
# HTN: The patient was continued on his home metoprolol 12.5 mg
BID.
.
# GERD: The patient was continued on lansoprazole 30 mg ___
.
# depression/insomnia: The patient was continued on mirtazapine
30 mg qhs
.. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
___: Laparoscopic Appendectomy
History of Present Illness:
___ experiencing ~24 hrs of abdominal pain that began as a band
across the upper abdomen and a band across the lower abdomen
that now focusing in the RLQ. The pain felt dizzy in the morning
and the pain began yesterday afternoon and worsened in intensity
through the night ___ by 3am). The pain was alleviated
somewhat by a bowel movement at 3am. The patient also reports
feeling the same dizziness she experiences episodes of
fibrillation, as well as nausea without vomiting and cold
sweats. Patient denies chest pain but endorses shortness of
breath. Pain is currently ___.
Past Medical History:
PMH:
- CAD w/ stends
- Hyperlipidemia
- Afib on Xarelto
- CAD: LAD with 60% and 80% serial lesions s/p DES ___
Social History:
___
Family History:
Father: Died at ___, myocarditis.
Mother: Died at ___, liver cancer (did not drink alcohol).
Paternal grandfather: Died of MI in ___.
No siblings. Three children all healthy.
Physical Exam:
GEN: NAD
HEENT: NCAT, EOMI, no scleral icterus
CV: RRR
RESP: no respiratory distress, breathing comfortably on room air
GI: soft, appropriately TTP, no R/G/D, laparoscopic port
incisions C/D/I and covered with Dermabond
EXT: WWP, no peripheral edema
Pertinent Results:
___ 08:50AM BLOOD WBC-13.9*# RBC-4.19 Hgb-13.0 Hct-37.9
MCV-91 MCH-31.0 MCHC-34.3 RDW-13.6 RDWSD-45.1 Plt ___
___ 06:55AM BLOOD ___ PTT-31.9 ___
___ 06:55AM BLOOD Glucose-81 UreaN-6 Creat-0.7 Na-140 K-4.0
Cl-105 HCO3-22 AnGap-17
___ 08:50AM BLOOD ALT-35 AST-29 AlkPhos-73 TotBili-1.2
___ 08:50AM BLOOD Lipase-26
___ 03:30PM BLOOD cTropnT-<0.01
___ 06:55AM BLOOD Calcium-8.7 Phos-3.0 Mg-1.9
___ 09:02AM BLOOD Lactate-1.3
CT A/P ___:
1. Acute appendicitis. No abscess demonstrated.
2. Diminutive enhancing focus within the uterus/endometrium,
likely an
endometrial polyp.
3. 1 cm pancreatic cystic lesion in the uncinate process may
represent a side branch IPMN.
Medications on Admission:
- Xarelto 20'
- metoprolol 50'
- atorvastatin 80'
- Aspirin 81'
- Nitroglycerin 0.4 as needed for angina
- Estradiol cream
Discharge Medications:
1. Acetaminophen 650 mg PO Q4H:PRN Pain - Mild
Reason for PRN duplicate override: Alternating agents for
similar severity
2. Ibuprofen 400 mg PO Q6H:PRN Pain - Moderate
Reason for PRN duplicate override: Alternating agents for
similar severity
3. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN Pain - Severe
4. Atorvastatin 80 mg PO QPM
5. Metoprolol Succinate XL 50 mg PO DAILY
6. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN prn chest pain
Discharge Disposition:
Home
Discharge Diagnosis:
Acute Appendicitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ with cough and fever// pna?
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph from ___
FINDINGS:
Lungs are well expanded and clear. The cardiomediastinal silhouette and hila
are within normal limits with redemonstrated tortuous aorta. There is no
pleural effusion or pneumothorax. Exaggerated thoracic kyphosis is unchanged.
IMPRESSION:
No focal consolidation to suggest pneumonia.
Radiology Report
INDICATION: ___ with lower abdominal pain // eval for acute process
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technique.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Stationary Acquisition 4.0 s, 0.5 cm; CTDIvol = 19.3 mGy (Body) DLP =
9.6 mGy-cm.
2) Spiral Acquisition 4.6 s, 50.4 cm; CTDIvol = 9.3 mGy (Body) DLP = 470.9
mGy-cm.
Total DLP (Body) = 481 mGy-cm.
COMPARISON: None.
FINDINGS:
LOWER CHEST: Lung bases are clear.
ABDOMEN:
HEPATOBILIARY: The liver and gallbladder are unremarkable.
PANCREAS: There is a 1 cm cystic lesion in the uncinate process. This may
represent an intraductal papillary mucinous neoplasm. No main ductal
dilatation seen.
SPLEEN: Unremarkable.
ADRENALS: Unremarkable.
URINARY: Unremarkable.
GASTROINTESTINAL: There is no bowel obstruction. The appendix is
fluid-filled, enlarged measuring maximally 13 mm with hyperemic mucosa and
wall edema (2:61, 602b:28, 601b:24). There is no free fluid or
pneumoperitoneum. No abscess is seen.
PELVIS: An enhancing 6 mm focus at the uterine fundus, likely an endometrial
polyp.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: A few left periuterine varices are noted. Mild atherosclerotic
calcifications.
BONES: No aggressive osseous lesion. Small fat containing umbilical hernia.
IMPRESSION:
1. Acute appendicitis. No abscess demonstrated.
2. Diminutive enhancing focus within the uterus/endometrium, likely an
endometrial polyp.
3. 1 cm pancreatic cystic lesion in the uncinate process may represent a side
branch IPMN.
*** ED URGENT ATTENTION ***
RECOMMENDATION(S): MRI follow-up for the pancreatic cystic lesion in ___ year.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 1:35 pm, 2 minutes after
discovery of the findings. The impression and recommendation above was entered
by Dr. ___ on ___ at 18:03 into the Department
of Radiology critical communications system for direct communication to the
referring provider.
Gender: F
Race: WHITE - OTHER EUROPEAN
Arrive by WALK IN
Chief complaint: Abd pain, Palpitations
Diagnosed with Unspecified abdominal pain
temperature: 100.7
heartrate: 80.0
resprate: 18.0
o2sat: 100.0
sbp: 116.0
dbp: 56.0
level of pain: 5
level of acuity: 3.0 | Ms. ___ is a ___ with acute appendicitis who was admitted
to the ___ on ___. The
patient was taken to the OR and underwent an uncomplicated
laparoscopic appendectomy. For details of the procedure, please
see the surgeon's operative note. The patient tolerated the
procedure well without complications and was brought to the
post-anesthesia care unit in stable condition. After a brief
stay, the patient was transferred to the surgery floor where he
remained through the rest of the hospitalization.
Post-operatively, she did well without any major issues. She was
able to tolerate a regular diet, get out of bed and ambulate
without assistance, void without issues, and pain was controlled
on oral medications alone. He was deemed ready for discharge,
and was given the appropriate discharge and follow-up
instructions.
She will restart her Xarelto and her Aspirin on POD#1. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Vicodin / Erythromycin Base / Lipitor / Penicillins
Attending: ___.
Chief Complaint:
Fatigue, lethargy, pain
Major Surgical or Invasive Procedure:
___ Superior hypogastric block with neurolysis
___ Ganglion impar block with neurolysis
History of Present Illness:
Mr ___ is a ___ yr old male with hx DM II, of
neuroendocrineCa of rectum metastatic to liver currently treated
w/ topotecan after progression on ___, C1D1 ___
who is admitted w/ severe hyperglycemia and pseudohypoNa.At his
last onc visit ___ he was noted to have some decline. was
having increased rectal pain requiring increased pain regimen
tofent patch 75mcg + oxycodone 20mg q3. pain attributed to
recent rectal XRT. Also more fatigued which was felt to be due
to under lying disease, XRT and recent chemo and narcotic use,
Ritalin use considered in future. He did not Glc level that
visit, but prior levels ranging high 100s to 300, appear to have
been elevated over the past ___ months. He has not been treated
w/ insulin or oral anti hypoglycemic agents thus far.
He was seen for C1D5 topotecan today, reported ongoing fatigue
and lethargy for 3 days and lightheadedness and urinary
frequency. Noted to have SBP 96, received 1L NS. He received
his treatment but found to have Glc 700+. He was also reporting
increased rectal pain w/ defecation. Pt was referred to ED for
treatment of hyperglycemia w/ plan for endocrine consult as well
as pain control and palliative consult.
Pt reports that at home he was never on meds including insulin
or metformin for previous diagnosis of diabetes, he lost weight
and was told didn't need treatment. Yesterday checked FSG
because he was urinating a lot(no dysuria) and machine read
>500.
Initial VS in ED 98.3 90 120/70 18 100%RA
Glc 730, AG 28, VBG w/ nl pH, bicarb 20
In ED pt was started on DKA protocol, received 1L NS, NS +40K @
250/hr. glucose improved to 610 and at 9:40 pm was down to 313.
On arrival to the floor he reports rectal pain and requesting
medication, denies hematochezia, diarrhea, constipation, abd
pain or nausea/vomiting. This is the same pain he has had since
diagnosis but seems to flare every now and then. Otherwise 10
point ROS neg.
Past Medical History:
PAST ONCOLOGIC HISTORY: per ___ initially presented in ___ with
hematochezia and rectal pain, and physical exam finding of a
rectal mass. On ___, he underwent pelvic MRI which
identified a tumor at the anorectal junction involving much of
the anus and left lower rectum invading along the left anorectal
wall. Multiple mesorectal lymph nodes were enlarged. On
___ he underwent colonoscopy under anesthesia.
Biopsy of the mass revealed poorly-differentiated carcinoma
consistent with large cell neuroendocrine carcinoma, staining
positive for cytokeratin, synaptophysin and chromogranin and
weakly positive for CDX2. Findings were consistent with
poorly-differentiated large cell neuroendocrine carcinoma. CT
torso ___ identified multiple liver lesions
consistent with metastases. On ___, Mr. ___
initiated palliative chemotherapy with carboplatin/etoposide.
-___ C1D1 ___
-___ C2D1 ___
-___: CT Torso: good PR
-___ C3D1 ___
-___ C4D1 ___
-___ C5D1 ___
-___: CT Torso with continued good PR
-___: C6D1 ___
-___: C7D1 ___
-___: CT Torso increased size of multiple liver mets
-___: C8D1 ___
-___: MRI pelvis showing increased primary tumor, stable
pelvic LN
-___: Palliative radiation to the rectum
-___: CTAP showing PD of liver mets
-___: Consented to topotecan
PAST MEDICAL HISTORY:
1. Basilar artery syndrome, status post TIA ___.
2. Type 2 diabetes mellitus, diet controlled.
3. Hypercholesterolemia.
4. Hypertension.
5. Obstructive sleep apnea.
6. Chronic low back pain.
Social History:
___
Family History:
Family History: The patient's mother died at ___ years with
ulcerative colitis. His father died at ___ years with
Alzheimer's
disease. His maternal grandfather was treated for head and neck
cancer at ___ years and died at ___ years. A paternal grandfather
died of cardiovascular disease. He has one brother who has
hypertension and a history of alcohol excess. He has two
daughters, one of whom is adopted, without health concerns.
Physical Exam:
ADMISSION PHYSICAL EXAM:
===============================
General: NAD
VITAL SIGNS: 104/56 98.4 79 16 97%RA
HEENT: MMM, no OP lesions,
Neck: supple, no JVD
Lymph: no cervical, supraclavicular, axillary or inguinal
adenopathy
CV: RR, NL S1S2 no S3S4 or MRG
PULM: CTAB
ABD: BS+, soft, NTND, no masses or hepatosplenomegaly
EXT: warm well perfused, no edema
SKIN: No rashes or skin breakdown
NEURO: alert and oriented x 4, ___, EOMI, no nystagmus, ___
strength trhoughout without tremor/asterixis
DISCHARGE PHYSICAL EXAM:
================================
Vitals: T 98.4 BP 94 / 56 HR 66 RR 18 98 RA
General: NAD
HEENT: MMM; OP clear
Neck: supple, no JVD
CV: RRR, normal S1/S2; no MRGs.
PULM: CTA b/l; no wheezes, rhonchi, or rales.
ABD: BS+, soft, NTND, no masses or hepatosplenomegaly
EXT: warm well perfused, no ___ edema
SKIN: No rashes or skin breakdown
NEURO: A&Ox3; CNs II-XII grossly intact.
Pertinent Results:
ADMISSION LABS:
==============================
___ 04:10PM BLOOD WBC-1.9*# RBC-2.74* Hgb-9.0* Hct-26.6*
MCV-97 MCH-32.8* MCHC-33.8 RDW-16.8* RDWSD-60.2* Plt Ct-74*#
___ 04:10PM BLOOD Plt Smr-VERY LOW Plt Ct-74*#
___ 04:10PM BLOOD UreaN-16 Creat-0.9 Na-125* K-4.4 Cl-81*
HCO3-20* AnGap-28*
___ 04:10PM BLOOD ALT-21 AST-17 LD(LDH)-171 AlkPhos-119
TotBili-0.7
___ 04:10PM BLOOD Albumin-4.0 Calcium-9.1 Phos-5.1* Mg-1.6
___ 07:17PM BLOOD %HbA1c-11.4* eAG-280*
___ 07:04PM BLOOD ___ pO2-45* pCO2-35 pH-7.43
calTCO2-24 Base XS-0
___ 07:04PM BLOOD Lactate-1.3
___ 06:50PM URINE Color-Straw Appear-Clear Sp ___
___ 06:50PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-1000 Ketone-40 Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
MICRO:
=================================
___ BLOOD CULTURE Blood Culture, Routine-PENDING
EMERGENCY WARD
___ BLOOD CULTURE Blood Culture, Routine-PENDING
EMERGENCY WARD
DISCHARGE LABS:
===============
___ 05:47AM BLOOD WBC-4.7 RBC-2.31* Hgb-7.5* Hct-23.8*
MCV-103* MCH-32.5* MCHC-31.5* RDW-18.3* RDWSD-69.3* Plt ___
___ 05:47AM BLOOD Glucose-119* UreaN-10 Creat-0.7 Na-131*
K-4.3 Cl-97 HCO3-28 AnGap-10
___ 05:47AM BLOOD Calcium-8.6 Phos-4.4 Mg-1.9
___ 05:50AM BLOOD calTIBC-196* Ferritn-1552* TRF-151*
___ 07:17PM BLOOD %HbA1c-11.4* eAG-280*
___ 04:07
C-PEPTIDE
Test Result Reference
Range/Units
C-PEPTIDE 0.49 L 0.80-3.85
ng/mL
THIS TEST WAS PERFORMED AT:
___ ___
___
Comment: C-PEPTIDE ADDED TO ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Tamsulosin 0.4 mg PO QHS
2. FoLIC Acid 1 mg PO DAILY
3. Atorvastatin 40 mg PO QPM
4. Fentanyl Patch 75 mcg/h TD Q72H
5. Aspirin 325 mg PO DAILY
6. Ondansetron 8 mg PO Q8H:PRN nausea
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
RX *acetaminophen 500 mg 2 tablet(s) by mouth Three times a day
Disp #*180 Tablet Refills:*0
2. Bisacodyl 10 mg PO DAILY:PRN constipation/hard stool
RX *bisacodyl [Laxative (bisacodyl)] 5 mg 2 tablet(s) by mouth
Once a day Disp #*14 Tablet Refills:*0
3. Docusate Sodium 200 mg PO BID
RX *docusate sodium 100 mg 2 tablet(s) by mouth Twice a day Disp
#*60 Tablet Refills:*0
4. Gabapentin 600 mg PO TID
RX *gabapentin 600 mg 1 tablet(s) by mouth Three times a day
Disp #*90 Tablet Refills:*0
5. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN Pain - Mild
RX *hydromorphone 4 mg ___ tablet(s) by mouth Every 3 hours Disp
#*60 Tablet Refills:*0
6. Glargine 5 Units Bedtime
Humalog 4 Units Breakfast
Humalog 4 Units Lunch
Humalog 4 Units Dinner
RX *insulin glargine [Lantus Solostar] 100 unit/mL (3 mL) AS DIR
5 Units before BED; Disp #*1 Syringe Refills:*0
RX *insulin lispro [Humalog KwikPen] 100 unit/mL AS DIR 4 units
before breakfast, lunch and dinner Disp #*1 Syringe Refills:*0
7. Methadone 7.5 mg PO Q8H
RX *methadone 5 mg ASDIR tabs by mouth Three times a day Disp
#*60 Tablet Refills:*0
8. Methadone 2.5 mg PO QHS
9. needle (disp) 31 gauge 31 gauge x ___ miscellaneous QID
BD Insulin pen needles ___ 31 gauge needle
Dispense 100
RX *needle (disp) 31 gauge [Easy Touch Hypodermic Needle] 31
gauge x ___ BD Insulin pen needles ___ 31 gauge needle QID
(at night and 3x with meals) Disp #*100 Box Refills:*3
10. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 17 gram 1 powder(s) by mouth Once a
day Disp #*30 Packet Refills:*0
11. Senna 17.2 mg PO BID
RX *sennosides 8.6 mg 2 tabs by mouth Twice a day Disp #*120
Tablet Refills:*0
12. Simethicone 120 mg PO QID:PRN gas pain
RX *simethicone 125 mg 1 tab by mouth Four times a day Disp #*60
Tablet Refills:*0
13. Aspirin 325 mg PO DAILY
14. Atorvastatin 40 mg PO QPM
15. FoLIC Acid 1 mg PO DAILY
16. Ondansetron 8 mg PO Q8H:PRN nausea
17. Tamsulosin 0.4 mg PO QHS
18.Glucometer
Please provide glucometer, lancets and test strips.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY:
Type 2 diabetes complicated by diabetic ketoacidosis
Metastatic neuroendocrine carcinoma of the rectum
SECONDARY:
Pain secondary to metastatic cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ with neutropenia and elevated glucose
COMPARISON: Prior CT of the chest dated ___
FINDINGS:
AP portable upright view of the chest. Overlying EKG leads are present.
There is no focal consolidation, effusion, or pneumothorax. The
cardiomediastinal silhouette is normal. Imaged osseous structures are intact.
IMPRESSION:
No acute intrathoracic process
Radiology Report
FINDINGS:
Chest fluoroscopy was performed in the OR without a Radiologist present.
Eight seconds of fluoro time was used. A single image was submitted to PACS.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Hyperglycemia, Rectal pain
Diagnosed with Hyperglycemia, unspecified, Other specified diseases of anus and rectum
temperature: 98.3
heartrate: 90.0
resprate: 18.0
o2sat: 100.0
sbp: 127.0
dbp: 70.0
level of pain: 5
level of acuity: 2.0 | Mr ___ is a ___ yr old male with hx DM II diet controlled,
recently diagnosed neuroendocrine carcinoma of rectum metastatic
to liver but no known pancreatic mets s/p recent Topetecan ___ who was admitted with lethargy, polyuria and polydipsia due
to severe hyperglycemia (FSBG >700) and severe rectal pain.
#Hyperglycemia, labile blood glucose, type 2 diabetes:
On admission, pt had severe hypoglycemia with FSBG of >700, with
anion gap, mild acidosis, positive urine ketones. Patient had
previously had diet controlled diabetes although review of BG
over past month frequently showed patient in the 200s. On
admission, it was unclear if patients hyperglycemia was provoked
by stress of underlying illness/chemotherapy, as topotecan is
not associated with hyperglycemia and there was no pancreatic
involvement on last staging scan ___. Patient had a negative
infectious workup, and patients acute presentation was most
likely due to progressive disease into insulin dependent DM.
Patient had C-peptide <.10, glucagon: <0.1, anti GAD: <5, IGF-1
24 (L). His glucose control was titrated on a basal-bolus
insulin regimen, with a stable dose found with Lantus 20 QHS and
Humalog 6U with meals. Patient received diabetes education with
___ diabetes educator, and was able to administer his own
insulin injections at the time of discharge.
#Rectal pain:
With regards to patients rectal pain, patient had experienced
substantial pain relief after recent XRT to the rectum 6 weeks
prior to admission. Patient was initially started on Methadone,
Gabapetin and oxycodone pro and patient received neurolysis
(hypogastric plexus block and ganglion impar) with Pain
Anesthesia on ___. Patients neurolysis did not provide
durable pain relief, and thus patients pain medication regimen
was uptitrated to a final regimen of methadone 7.5MG AM, 7.5MG
noon, 10mg ___ dosing with po Dilaudid ___ q3h prn for
breakthrough pain and Gabapentin 600mg po TID to cover his
neuropathic pain, which he tolerated well. He received repeat
interventional procedure ___ Ganglion impar block with
neurolysis with good effect. Pain well controlled at time of
discharge.
# Pancytopenia:
During this admission, patient had neutropenia/pancytopenia at
the time of admission in the setting of recent marrow
suppressive therapy (topetecan). He received Neupogen with good
effect, which was d/c'ed once his counts had normalized. He
received the first dose of C2 of topetecan on this admission,
with plan to continue this as an outpatient for the remaining
doses in his cycle.
# Pseudohyponatremia:
During this admission, pt was noted to have pseudohyponatremia
in the setting of elevated blood sugars. Patients hyponatremia
corrected with correction of patients blood glucose.
# Metastatic neuroendocrine cancer:
He had primary rectal mass with meatastasis to liver, and
progressive disease after ___. He started topotecan
___. He will follow up with outpatient oncologist (Dr. ___
after discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
___: US-guided percutaneous cholecystectomy drain placement
History of Present Illness:
This is a ___ year-old gentleman with history of rectal cancer
s/p low anterior resection and diverting ileostomy with
subsequent takedown (___), who was recently admitted to the
hospital given a 5-day history of abdominal pain, found on
workup to have acute cholecystitis. Given duration of symptoms,
decision was made to treat non-operatively and administer
antibiotics (percutaneous cholecystostomy tube placement was not
pursued given minimal
gallbladder distention). He responded well to initial therapy
and was discharged home after a 24-hour stay, having tolerated
clear liquids diet and being free of pain.
He now presents less than 12 hours after discharge with
recurrent abdominal pain, which appeared shortly after dinner
consisting of spinach omelette and rice. Similar to his previous
pain, he describes it as sharp and severe, located over his
epigastrium and radiating towards the right upper quadrant and
back. Pain worsens with deep inspiration. Concomitantly, he
endorses nausea
but no emesis, chills but no fever, as well as bloating
sensation, mostly after meals.
Past Medical History:
PMH: none
PSH: none
Social History:
___
Family History:
Noncontributory
Physical Exam:
On admission:
Vital signs - 98.3 74 117/67 18 99% RA
Constitutional - Well appearing, in no acute distress
Cardiopulmonary - RRR, normal S1 and S2. No murmurs, rubs or
gallops. Lungs are clear to auscultation bilaterally
Abdominal - Well healed incisional scars from prior operations.
Soft, mildly distended, tender over epigastrium and right upper
quadrant with voluntary guarding. No rebound tenderness
Extremities - Atraumatic. Warm and well-perfused
Neurologic - Grossly intact. Alert and oriented x 3
On discharge:
VSS
Gen: NAD
Chest: RRR, CTAB
Abd: soft, nondistended. no tenderness. No rebound or rigidity.
Drain in place
extr: no edema
Pertinent Results:
___ 04:10AM PLT COUNT-177
___ 04:10AM WBC-6.8 RBC-5.02 HGB-15.0 HCT-42.7 MCV-85
MCH-29.9 MCHC-35.2* RDW-14.1
___ 04:10AM CALCIUM-8.5 PHOSPHATE-3.9 MAGNESIUM-2.1
___ 04:10AM GLUCOSE-80 UREA N-15 CREAT-0.9 SODIUM-138
POTASSIUM-4.0 CHLORIDE-101 TOTAL CO2-27 ANION GAP-14
___ 12:14AM ___ PTT-29.7 ___
___ 12:14AM PLT COUNT-212
___ 12:14AM NEUTS-57.8 ___ MONOS-6.2 EOS-6.1*
BASOS-0.5
___ 12:14AM WBC-8.0 RBC-5.21 HGB-15.6 HCT-42.5 MCV-82
MCH-30.0 MCHC-36.7* RDW-13.6
___ 12:14AM ALBUMIN-4.2
___ 12:14AM LIPASE-55
___ 12:14AM ALT(SGPT)-34 AST(SGOT)-21 ALK PHOS-62 TOT
BILI-0.6
___ 12:14AM GLUCOSE-140* UREA N-23* CREAT-0.9 SODIUM-138
POTASSIUM-4.1 CHLORIDE-101 TOTAL CO2-28 ANION GAP-13
Medications on Admission:
none
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN mild pain
RX *acetaminophen 325 mg ___ tablet(s) by mouth every 6 hours
Disp #*50 Tablet Refills:*0
2. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 10 Days
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth twice daily Disp #*20 Tablet Refills:*0
3. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN moderate
pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every 4 hours Disp
#*40 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Cholecystitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: Ultrasound guided percutaneous cholecystostomy.
INDICATION: ___ year old man with chronic cholecystitis // please evaluate
for percutaneous cholecystostomy tube placement
COMPARISON: Abdominal ultrasound ___.
PROCEDURE: Ultrasound-guided percutaneous cholecystostomy.
OPERATORS: Dr. ___ trainee and Dr. ___
radiologist. Dr. ___ supervised the trainee during the key
components of the procedure and reviewed and agrees with the trainee's
findings.
TECHNIQUE: The risks, benefits, and alternatives of the procedure were
explained to the patient with use of interpreter service. After a detailed
discussion, informed written consent was obtained. A pre-procedure timeout
using three patient identifiers was performed per ___ protocol.
The patient was placed in a slight left posterior oblique position on the
ultrasound table. Limited preprocedure imaging was performed to localize the
gallbladder. An appropriate skin entry site was chosen and the site marked.
Local anesthesia was administered with 1% Lidocaine solution.
Using continuous sonographic guidance, an ___ Exodus drainage catheter
was advanced via trocar technique. The wall of the gallbladder was difficult
to traverse, likely due to chronic inflammation. Gentle aspiration was
attempted times which failed to yield bilious fluid. Patient began to
experience significant pain at which time procedure was aborted.
Given sudden increase in patient pain, a noncontrast CT abdomen was obtained
to evaluate for acute abdominal process and is dictated under separate
accession number.
SEDATION: Moderate sedation was provided by administering divided doses of
4.5 mg Versed and 250 mcg fentanyl throughout the total intra-service time of
110 minutes during which patient's hemodynamic parameters were continuously
monitored by an independent trained radiology nurse.
FINDINGS:
Gallbladder wall is dilated measuring up to 8 mm in thickness. There are
echogenic structures with posterior acoustic shadowing consistent with
gallstones.
IMPRESSION:
Attempted ultrasound guided percutaneous cholecystostomy was aborted due to
difficulty traversing the thickened, likely chronically inflamed gallbladder
wall and due to patient pain.
Radiology Report
EXAMINATION: CT abdomen without contrast.
INDICATION: Followup ultrasound.
TECHNIQUE: MDCT axial images were acquired through abdomen and pelvis without
the intravenous contrast administration.
Coronal and sagittal reformations were performed and reviewed on PACS.
Oral contrast was not administered.
DOSE: DLP: 365 mGy-cm (abdomen and pelvis.
COMPARISON: Same date ultrasound. CT abdomen ___.
FINDINGS:
LOWER CHEST:
Bibasilar atelectasis is mild. The the there is no pleural or pericardial
effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesions. There is no evidence of intrahepatic
or extrahepatic biliary dilatation. Gallbladder wall thickening is re-
demonstrated. Dense material within dependent aspect of the gallbladder likely
represents vicarious excretion of intravenous contrast from prior CT ___. There are small foci of free air at the level of the falciform ligament.
Small amount of free air is also visualized anterior to the right renal vein
with suggestion of tracking towards the gallbladder fossa. There is no
intra-abdominal free fluid.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size There is no evidence of
stones or hydronephrosis.
GASTROINTESTINAL: Small bowel loops demonstrate normal caliber, wall
thickness and enhancement throughout. Visualized colon is within normal
limits.
RETROPERITONEUM: There is no evidence of retroperitoneal and mesenteric
lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. There is no calcium burden
in the abdominal aorta and great abdominal arteries.
BONES AND SOFT TISSUES:
There is no evidence of worrisome lesions. Abdominal and pelvic wall is within
normal limits.
IMPRESSION:
1. Small amount of free air posterior to the pancreas with questionable
extension to the gallbladder fossa. This air may have been introduced at time
of procedure during aspiration or when the stylet was placed back in the
catheter. There is no abdominal fluid collection. Additional small foci of
air anterior to the falciform ligament and along the right anterior hepatic
margin (03:23)
2. Gallbladder wall thickening consistent with chronic cholecystitis.
Dependent hyperintense material within the gallbladder lumen likely represent
vicarious contrast excretion from prior CT. This would indicate patent cystic
duct.
NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___ on the
telephone on ___ at 1:37 ___.
Radiology Report
EXAMINATION: Ultrasound-guided percutaneous cholecystostomy tube placement
INDICATION: ___ year old man with acute cholecystitis
COMPARISON: Ultrasound from ___
PROCEDURE: Ultrasound-guided percutaneous cholecystostomy.
OPERATORS: Dr. ___ fellow and Dr. ___
radiologist. Dr. ___ supervised the trainee during the key
components of the procedure and reviewed and agrees with the trainee's
findings.
TECHNIQUE: The risks, benefits, and alternatives of the procedure were
explained to the patient. After a detailed discussion, informed written
consent was obtained. A pre-procedure timeout using three patient identifiers
was performed per ___ protocol.
The patient was placed in a supine position on the ultrasound table. Limited
preprocedure imaging was performed to localize the gallbladder. An
appropriate skin entry site was chosen and the site marked. Local anesthesia
was administered with 1% Lidocaine solution.
Using continuous sonographic guidance, an ___ drainage catheter
was advanced via trocar technique into the gallbladder. A sample of fluid was
aspirated, confirming catheter position within the collection. The plastic
stiffener was removed. The pigtail was deployed. The position of the pigtail
was confirmed within the collection via ultrasound. Ultrasound images were
stored on PACS.
Approximately 15 cc of black, bilious fluid was drained with a sample sent for
microbiology evaluation. The catheter was secured by a StatLock. The catheter
was attached to bag. Sterile dressing was applied.
The procedure was tolerated well, and there were no immediate post-procedural
complications.
SEDATION: Moderate sedation was provided by administering divided doses of 2
mg Versed and 100 mcg fentanyl throughout the total intra-service time of 15
minutes during which patient's hemodynamic parameters were continuously
monitored by an independent trained radiology nurse.
FINDINGS:
Limited preprocedure ultrasound of the right upper quadrant demonstrates a
gallbladder with wall thickening that is not significantly distended and is
similar to the prior ultrasound -for further details please see recent
ultrasound and CT from ___.
IMPRESSION:
Successful ultrasound-guided placement of ___ pigtail catheter into the
gallbladder. Samples was sent for microbiology evaluation.
Gender: M
Race: WHITE - BRAZILIAN
Arrive by WALK IN
Chief complaint: Abd pain
Diagnosed with ACUTE CHOLECYSTITIS, ABDOMINAL PAIN RUQ, ABDOMINAL PAIN EPIGASTRIC
temperature: 98.3
heartrate: 74.0
resprate: 18.0
o2sat: 99.0
sbp: 117.0
dbp: 67.0
level of pain: 10
level of acuity: 3.0 | ___ was admitted on ___ under the acute care
surgery service for management of abdominal pain suspicious for
acute cholecystitis. Given the duration of symptoms and the
history of present illness, the option to have the patient
undergo a cholecystectomy was deferred. Rather, a percutaneous
cholecystotomy tube was done. The patient tolerated the
procedure well with no complications. He recovered well
afterwards.
He was transferred to the surgical floor hemodynamically stable.
His vital signs were routinely monitored and she remained
afebrile and hemodynamically stable. He was initially given IV
fluids postoperatively, which were discontinued when he was
tolerating PO's. Her diet was advanced to clears and then
subsequently a regular diet, which he tolerated without
abdominal pain, nausea, or vomiting. He was voiding adequate
amounts of urine without difficulty. He was encouraged to
mobilize out of bed and ambulate as tolerated, which she was
able to do independently. His pain level was routinely assessed
and well controlled at discharge with an oral regimen as needed.
On ___ she was discharged home with scheduled follow up in
___ clinic in 2 weeks |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with h/o HTN, HLD, prostate CA s/p resection ___, PMR on
prednisone, recently admitted to ___ ___ for inferior
STEMI, now presenting with 3 days of tachycardia, chills,
malaise, and foul smelling urine at home.
Pt reports that on ___ he began feeling unwell. He had
been monitoring his HR and BP since discharge, and he noticed
that his heart was "fast" and he could feel it pounding in his
chest. His body felt "sloshy" and very weak. This got worse on
___. On ___ he presented to the ED. He denies ever having
chest pain. He did feel some occasional need to catch his breath
randomly when lying in bed. But it resolved by taking a few deep
breaths. He denies DOE or PND. No weight gain ___ edema. No
cough.
He never checked a temperature at home or felt febrile, but he
did have chills/sweats. He had foul smelling urine and increased
urinary frequency but no dysuria. He never had nausea, vomiting,
abdominal pain, diarrhea, constipation, HA, myalgias or
arthralgias. His malaise improved significantly in the ED with
treatment, as did his "palpitations." In the ED he started
getting RLQ pain similar to urologic pain he has had in the
past. He denies flank pain.
In the ED, initial vitals: 101.3 105 ___ 97% RA. Pt HR
improved to ___. Pt fever came down to 99.6, but he
re-spiked to 102.9. Labs/Studies notable for: trop 0.02 x3, Cr
1.5 (baseline 1.7), WBC 11.8, and positive UA. Blood and urine
cultures were not drawn. EKG showed NA/NI, TWI in II, III, and
aVF stable from EKG post cath on ___. CXR showed no acute CP
process. He developed LUQ pain while being obs'd in the ED, so
CT A/P was performed to r/o nephrolithiasis. It showed chronic
left UPJ obstruction with severe hydronephrosis of the left
kidney, no ureteral stone visualized, + tranding about the left
kidney. Urology was consulted, who felt that the findings were
chronic and pt should be treated for pyelonephritis. Patient was
given: 1L NS and cipro 750mg.
Vitals prior to transfer: 98.6 85 107/55 20 97% RA.
Of note, pt was recently admitted for inferior stemi. At___
cardiology was consulted in the ED who recommended trending
troponin x3 to r/o instent restenosis. Troponins were flat at
0.02. Atrius cardiology had no further recommendations.
Currently, he feels well and all of the above symptoms have
resolved.
Past Medical History:
HTN
HLD
Polymyalgia Rheumatica - Temporal artery bx negative, C-Spine
imaging negative
CKD stage 3, GFR ___ ml/min - ___ left UPJ obstruction w/ out
improvement s/p stenting ___ so stent removed ___
Prostate cancer (s/p prostatectomy) ___
TREMOR
BASAL CELL CARCINOMA
Colonic adenoma
KERATOSIS - ACTINIC
THYROID NODULE
GLAUCOMA SUSPECT
HEADACHE
LOW BACK PAIN
DISC DISORDER OF LUMBAR REGION
CAD - Inferior STEMI ___ s/p DES to RCA
Social History:
___
Family History:
Glaucoma: mother, ___, and sister
Brother - ___ retina, retinal Hole
no hx of ESRD or CKD. Mother died of CHF, brother has unknown
arrhythmia
Physical Exam:
Admission exam:
Vitals: 98.4, 117/76, 99, 16, 100% on RA
General: AAOx3, pleasant, comfortable appearing, NAD
HEENT: EOMI, PERRL, MMM. OP clear. sclera anicteric.
Neck: no JVP, supple, no LAD
Lungs: CTAB, no w/r/r
CV: RRR, no m/g/r
Abdomen: nabs, s, nd, mildly ttp in LLQ without rebound or
guarding
GU: no foley
Ext: wwp, no edema
Neuro: CNs II-XII intact, ___ strength, normal gait.
Discharge exam:
VS- 102.5 @ ___ yesterday, ___ 88-121 18 97%RA
Gen: Ambulating through hall, AAOx3
HEENT: MMM, anicteric
CV: S1S2 RRR no m/g/c/r
PULM: CTAB
Abd: Mild TTP in LLQ, no r/g
Ext: No c/c/e
Back: L CVA tenderness
Pertinent Results:
Admission labs:
___ 02:00PM BLOOD WBC-11.8*# RBC-3.85* Hgb-12.5* Hct-35.9*
MCV-93 MCH-32.4* MCHC-34.8 RDW-14.0 Plt ___
___ 02:00PM BLOOD Neuts-89.8* Lymphs-4.8* Monos-5.1 Eos-0.2
Baso-0.1
___ 02:00PM BLOOD Glucose-132* UreaN-22* Creat-1.5* Na-134
K-4.2 Cl-98 HCO3-24 AnGap-16
___ 02:00PM BLOOD cTropnT-0.02*
___ 08:30PM BLOOD cTropnT-0.02*
___ 01:55AM BLOOD cTropnT-0.02*
Discharge labs:
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
___ 08:30 9.9 3.97* 12.5* 37.0* 93 31.6 34.0 13.8 272
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
___ 08:30 ___ 130* 3.7 91* 25 18
Micro:
___ 5:33 pm URINE Site: NOT SPECIFIED
CHEM# ___ ___.
**FINAL REPORT ___
URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 32 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Imaging:
___ EKG: NA/NI, TWI in II, III, and aVF stable from EKG post
cath on ___
___ EKG: NA/NI, TWI in II, III, and aVF stable from EKG post
cath on ___
___ CT Abdomen/pelvis
1. Chronic left UPJ obstruction with severe hydronephrosis of
the left kidney. Thickening of left perinephric septae may be
chronic or due to recent forniceal rupture. Evaluation for
pyelonephritis cannot be performed in the absence of IV
contrast.
2. Status post prostatectomy without sign of metastatic disease.
___ CXR:
No acute cardiopulmonary process.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Losartan Potassium 12.5 mg PO DAILY
2. Multivitamins W/minerals 1 TAB PO DAILY
3. PredniSONE 8 mg PO DAILY
Tapered dose - DOWN
4. Vitamin D ___ UNIT PO DAILY
5. Aspirin 81 mg PO DAILY
6. Atorvastatin 80 mg PO DAILY
7. Metoprolol Succinate XL 50 mg PO DAILY
8. TiCAGRELOR 90 mg PO BID
9. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO DAILY
3. Losartan Potassium 12.5 mg PO DAILY
4. Metoprolol Succinate XL 50 mg PO DAILY
5. Multivitamins W/minerals 1 TAB PO DAILY
6. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
7. PredniSONE 8 mg PO DAILY
Tapered dose - DOWN
8. TiCAGRELOR 90 mg PO BID
9. Vitamin D ___ UNIT PO DAILY
10. Cefpodoxime Proxetil 200 mg PO Q12H
12 days of treatment
RX *cefpodoxime 200 mg 1 tablet(s) by mouth every 12 hours Disp
#*24 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Pyelonephritis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: Chest radiograph
INDICATION: History: ___ with fatigue +fever // pneumonia?
TECHNIQUE: Chest PA and lateral
COMPARISON: None.
FINDINGS:
Heart size is normal. Cardiomediastinal silhouette and hilar contours are
unremarkable. Lungs are clear. There is trace bibasilar atelectasis. There
is no edema. Pleural surfaces are clear without effusion or pneumothorax.
IMPRESSION:
No acute cardiopulmonary abnormality.
Radiology Report
INDICATION: ___ with ckd with LLQ pain and UTI.
TECHNIQUE: Non-contrast scan: Multidetector CT images of the abdomen and
pelvis were acquired without intravenous contrast with the patient in the
prone position. Non-contrast scan has several limitations in detecting
vascular and parenchymal organ abnormalities, including tumor detection.
Coronal and sagittal reformations were performed and submitted to PACS for
review.
No oral contrast was administered.
DOSE: DLP: 524.45 mGy-cm (abdomen and pelvis.
COMPARISON: None.
FINDINGS:
LOWER CHEST:
Bibasilar scarring is present. The heart is normal in size.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no evidence of intrahepatic or extrahepatic biliary dilatation. The
gallbladder is within normal limits, without stones or gallbladder wall
thickening.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
pancreatic ductal dilatation. There is no peripancreatic stranding.
SPLEEN: The spleen shows normal size and attenuation throughout.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The noncontrast appearance of the right kidney is unremarkable.
Chronic UVJ obstruction is seen in the left kidney with severe hydronephrosis.
There is no left hydroureter. Perinephric stranding without fluid collection
is noted about septal thickening the left kidney, which is nonspecific.
Ureteral stone is visualized.
GASTROINTESTINAL: Small bowel loops demonstrate normal caliber, wall
thickness and enhancement throughout. Colon and rectum are within normal
limits. Appendix contains air, has normal caliber without evidence of fat
stranding.
RETROPERITONEUM: There is no evidence of retroperitoneal and mesenteric
lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. There is minimal calcium
burden in the abdominal aorta and great abdominal arteries.
PELVIS:
The urinary bladder and distal ureters are unremarkable. Surgical clips along
the external and common iliac lymph node chains bilaterally is consistent with
prior lymph node dissection. There is no free fluid in the pelvis.
REPRODUCTIVE ORGANS: The patient is status post prostatectomy.
BONES AND SOFT TISSUES:
There is no evidence of worrisome lesions. L5-S1 degenerative changes are
noted. Abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. Chronic left UPJ obstruction with severe hydronephrosis of the left kidney.
Thickening of left perinephric septae may be chronic or due to recent
forniceal rupture. Evaluation for pyelonephritis cannot be performed in the
absence of IV contrast.
2. Status post prostatectomy without sign of metastatic disease.
NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___ on
the telephone on ___ at 9:09 AM.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Dyspnea
Diagnosed with CHEST PAIN NOS, URIN TRACT INFECTION NOS, RESPIRATORY ABNORM NEC
temperature: 101.3
heartrate: 105.0
resprate: 16.0
o2sat: 97.0
sbp: 107.0
dbp: 74.0
level of pain: 0
level of acuity: 2.0 | ___ with PMH HTN, HLD, PMR on prednisone, chronic L
hydronephrosis s/p stent placement and removal in early ___,
recently admitted for inferior STEMI, now presenting with fevers
and foul smelling urine, CT A/P concerning for pyelonephritis.
# Pyelonephritis:
Pt was started on empiric ceftriaxone with subsequent
improvement in fevers and leukocytosis. Given his complicated
urologic history, Urology was formally consulted. They had no
additional recommendations regarding his L hydronephrosis since
he appeared to be improving clinically. Antibiotics were
narrowed, and the pt was discharged on a 14 day course of
cefpodoxime. Culture results after discharge revealed e coli
sensitive to cephalosporins.
# CAD s/p inferior STEMI ___:
Given pt's report of some SOB on admission, pt was worked up for
recurrent STEMI vs instent restenosis. Pt never endorsed CP and
SOB was not c/w cardiac etiology. No clinical findings of heart
failure. Troponins were 0.02 x3 with no EKG changes. SOB
resolved. Atrius cardiology was made aware and felt a formal
consult was not needed. He was continued on his home ___,
ticagrelor, atorvastatin, and metoprolol.
# CKD Stage III:
Baseline Cr 1.7 per prior records. No evidence of acute injury.
s/p 1L NS in the ED. Cr here improved to 1.3 by discharged after
IV fluids. He was discharged on his home losartan and vitamin D
and will follow up with his renal doctors.
# PMR:
Pt recently diagnosed in ___. Continued on his home
prednisone taper. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
Penicillins
Attending: ___
Chief Complaint:
fever, LLQ pain
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
___ yo with hx of fallopian cancer and known left lymphocele
presents with fever and LLQ pain PPD ___ s/p ___ drainge. She has
been on oral levo and flagyl but depite this had a temp of 100.9
today. She was directed to the ED where she had a CT abd/pelvis
for evaluate for collection. On ROS she notes right sided flank
pain consistent with her prior infected lymphoceles. Otherwise
eating well without difficulty. No CP, SOB. No other
complaints.
Past Medical History:
Gyn-onc hx:
-stage IA, grade 3 papillary serous right fallopian tube cancer
and underwent a staging surgery ___ (Laparoscopy, total
laparoscopic hysterectomy, bilateral salpingo-oophorectomy,
laparoscopic total pelvic lymphadenectomy, laparoscopic
para-aortic lymph node resection, infracolic omentectomy,
peritoneal biopsy, cystoscopy).
-s/p chemotherapy (six cycles of adjuvant chemotherapy with
carboplatin and paclitaxel), completed on ___
-lymphoceles bilaterally, with infection on the right side, s/p
drainage on ___, recurrence on the left side by ___.
-most recent CA 125 ___ = 10 (at 10 since ___
-BRCA testing negative
OB/GYN History:
-G2P0, 2 TABs in the early ___
-cervical dysplasia that was treated with cryosurgery
-history of PID, warts, and gonorrhea
-history of infertility.
-history of Dalkon Shied use, which was taken care of with
removal of the IUD secondary to pain.
Current Medications:
Past Medical History:
-reflux: for which she uses Nexium.
Past Surgical History:
-cryosurgery of the cervix in ___ for cervical dysplasia
-Laparoscopy, total laparoscopic hysterectomy, bilateral
salpingo-oophorectomy, laparoscopic total pelvic
lymphadenectomy,
laparoscopic para-aortic lymph node resection, infracolic
omentectomy, peritoneal biopsy, cystoscopy ___
Social History:
___
Family History:
She denies any family history of breast cancer, ovarian cancer,
or uterine cancer. She denies family history of other
gynecologic malignancies. She reports her mother had polyps of
the colon and a paternal uncle had colon cancer.
Physical Exam:
On admission:
VS: 100.2 89 159/71 16 99% RA
Gen: NAD
Card: Regular rate, +SEM (___)
Resp: Clear bilaterally
Flank: No CVAT, right sided soreness
Abd: Soft, no rebound or guarding, +TTP in LLQ -> healing <1cm
incision from ___ without signs of superficial infection. +BS
Pelvic: Deferred
Ext: NT, NE
On discharge:
VS: afebrile, AVSS
Gen: NAD
Card: RRR
Resp: Clear bilaterally
Flank: No CVAT
Abd: Soft, no rebound or guarding,
Pelvic: Deferred
Ext: NT, NE
Pertinent Results:
___ 09:50PM BLOOD WBC-5.7 RBC-3.24* Hgb-10.6* Hct-32.0*
MCV-99* MCH-32.7* MCHC-33.1 RDW-12.1 Plt ___
___ 06:30AM BLOOD WBC-5.8 RBC-3.15* Hgb-10.2* Hct-31.3*
MCV-99* MCH-32.2* MCHC-32.5 RDW-13.2 Plt ___
___ 09:50PM BLOOD ___ PTT-30.3 ___
___ 06:45AM BLOOD ___ PTT-32.3 ___
___ 09:50PM BLOOD Glucose-94 UreaN-14 Creat-0.8 Na-140
K-4.1 Cl-104 HCO3-28 AnGap-12
___ 06:30AM BLOOD Glucose-92 UreaN-10 Creat-0.7 Na-142
K-4.4 Cl-104 HCO3-30 AnGap-12
___ 06:45AM BLOOD Calcium-8.5 Phos-3.5# Mg-2.0
___ 06:30AM BLOOD Calcium-8.9 Phos-3.7 Mg-2.0
CT of abd/pelvis ___: Interval partial re-accumulation of
left-sided pelvic wall fluid collection with rim enhancement,
with surrounding fat stranding and adjacent enlarged inguinal
lymph node similar to the prior imaging appearance. Though CT
cannot exclude the presence of infection, the imaging features
are noted to be similar to the previous, pre-drainage
examination.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. MetRONIDAZOLE (FLagyl) 500 mg PO TID
2. Levofloxacin 500 mg PO Q24H
3. NexIUM *NF* (esomeprazole magnesium) 40 mg Oral daily
Discharge Medications:
1. Levofloxacin 750 mg PO Q24H Duration: 10 Days
RX *Levaquin 750 mg 1 tablet(s) by mouth once a day Disp #*10
Tablet Refills:*0
2. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H Duration: 10 Days
RX *metronidazole 500 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*30 Tablet Refills:*0
3. NexIUM *NF* (esomeprazole magnesium) 40 mg ORAL DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
fever likely due to infected lymphocysts.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Recent ___ drainage of lymphocele, now with fever. Patient has
history of fallopian tube cancer and known prior lymphocele.
TECHNIQUE: Multidetector helical CT scan of the abdomen and pelvis was
obtained after the administration of 130 cc IV Omnipaque contrast. Coronal
and sagittal reformations were prepared.
COMPARISON: Multiple prior examinations, most recent dedicated CT dated ___ and review of CT images from drainage procedure dated ___.
FINDINGS: As compared to the post-procedure images from the prior drainage,
there has been partial re-accumulation of a left pelvic fluid collection now
measuring 3.3 x 2.7 cm (2:62) in the same location, though smaller than the
previously drained collection. There is again surrounding rim enhancement. A
2.2 x 1.4 cm left inguinal lymph node (2:68) is unchanged. Mild fat stranding
surrounding the fluid collection is similar to the prior examination.
The included portions of the lung bases demonstrate a stable right subpleural
nodule (2:10). The liver, spleen, pancreas, adrenal glands, and kidneys
appear grossly unremarkable. The gallbladder is minimally distended, however,
otherwise normal. Visualized loops of small and large bowel are normal in
size and caliber. Multiple surgical clips from prior lymph node dissection
are noted. No abdominal free air, free fluid collection or lymphadenopathy is
seen.
Within the pelvis, the bladder and distal ureters appear unremarkable. The
patient is status post hysterectomy. Distal loops of large bowel and rectum
are normal in size and caliber. There are scattered diverticula; however, no
evidence of diverticulitis is seen. Again surgical clips from lymph node
dissection are noted.
No concerning osseous lesion is seen.
IMPRESSION: Interval partial re-accumulation of left-sided pelvic wall fluid
collection with rim enhancement, with surrounding fat stranding and adjacent
enlarged inguinal lymph node similar to the prior imaging appearance. Though
CT cannot exclude the presence of infection, the imaging features are noted to
be similar to the previous, pre-drainage examination.
Gender: F
Race: WHITE
Arrive by OTHER
Chief complaint: R/O INFECTION
Diagnosed with FEVER, UNSPECIFIED
temperature: 100.2
heartrate: 89.0
resprate: 16.0
o2sat: 99.0
sbp: 159.0
dbp: 71.0
level of pain: 2
level of acuity: 3.0 | ___ was admitted to the gyn-onc service for fever and
possible infected lymphocele. Labs and CT of the abdomen/pelvis
were obtained for evaluation. The WBC remained stable and WNL
throughout her hospital stay. The rest of her fever workup was
negative (except the blood cultures were pending at the time of
her discharge). Pt was initially started on IV Levofloxacin and
Flagyl and then transitioned to PO Levofloxacin and Flagyl. Pt's
fever curve was monitored closely. After her antibiotics were
changed to PO form, she remained afebrile. She was discharged
home on HD#4 in stable condition. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfamethizole
Attending: ___.
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
___: Coronary angiogram
Coronary Description
The coronary circulation is right dominant.
LM: The Left Main, arising from the left cusp, is a large
caliber vessel. This vessel bifurcates into the Left Anterior
Descending and Left Circumflex systems.
LAD: The Left Anterior Descending artery, which arises from the
LM, is a large caliber vessel.
The Diagonal, arising from the proximal segment, is a medium
caliber vessel.
Cx: The Circumflex artery, which arises from the LM, is a large
caliber vessel.
The ___ Obtuse Marginal, arising from the proximal segment, is a
medium caliber vessel.
The ___ Obtuse Marginal, arising from the mid segment, is a
medium caliber vessel.
RCA: The Right Coronary Artery, arising from the right cusp, is
a large caliber vessel.
The Right Posterior Descending Artery, arising from the distal
segment, is a medium caliber vessel.
The Right Posterolateral Artery, arising from the distal
segment, is a medium caliber vessel.
Interventional Details
Complications: There were no clinically significant
complications.
Findings
No angiographically apparent coronary artery disease.
History of Present Illness:
___ y F with history of Raynauds, depression, anxiety, who
presented with chest pain, found to have ST elevations in
anterolateral leads s/p cardiac catheterization without coronary
artery disease, now admitted to cardiology NP service.
She reports waking up from sleep with chest pain. Feels like she
can't take a deep breath. Feels like a pressure, radiating into
the jaw. Her chest pain is worse when lying flat. She has no
family history of cardiac disease. No HTN, HLD, diabetes, or
smoking.
- In the ED, initial vitals were:70 ___ 100% RA
- Labs were notable for: trop 1.12, BNP 451 wbc 10.2, hgb 12.5,
plt 219, Na 135, K 4.2, Cl 95, bicarb 24, BUN 22, Cr 0.8,
- Studies were notable for: EKG NSR HR 75 ST elevations in I,
V3-V6, no reciprocal changes, normal intervals
CXR: No acute cardiopulmonary abnormality.
- The patient was given: ASA 325, nitro SL, heparin gtt
Code STEMI was called and she was taken to cath lab, underwent
angiogram with right radial access, found to have no
angiographically apparent coronary artery disease.
On arrival to the floor, VSS: T:98.3 BP: 99/62 HR:69 RR:18
SpO2: 99% RA. She reports ongoing chest "tightness" that has
improved from the chest pressure she felt overnight. She denies
shortness of breath, lightheadedness/ dizziness.
Past Medical History:
anxiety
depression
osteoporosis
Raynauds
Social History:
___
Family History:
paternal aunt breast cancer, no ovarian or colon cancers, no
diabetics, no premature cad, no clotting disorders, melanoma, no
d/s/etoh.
Physical Exam:
Physical Exam on Admission:
General: Awake, pleasant female lying in bed appears to be in no
acute distress
Neuro: Alert and oriented x4. Pleasant and cooperative. Speech
clear, appropriate and comprehensible. Tongue midline, smile
symmetric. Equal and strong hand grasps and foot pushes.
HEENT: Neck supple, No JVD noted
CV: RRR, Normal S1/S2, no murmur
Lungs: Clear ___, posteriorly, respirations are non-labored. No
use of accessory muscles noted.
Abdomen: soft, non-tender
PV: WWP, No edema
Access sites: Right radial soft without bleeding or hematoma. +2
radial pulse. CSM WNL.
Physical Exam on Discharge:
___ 0734 Temp: 99.8 PO BP: 103/62 R Lying HR: 85 RR: 18
O2 sat: 93% O2 delivery: Ra
___ 0803 BP: 113/56 R Sitting HR: 83
___ 1312 BP: 89/53 R Sitting HR: ___ FSBG: ___ mild
___,
___ PO Amt: 420ml
___ Urine Amt: 1575ml
Today's Weight: 62.5 kg
Tele: SR 60-80s, no arrhythmia alarms per telemetry review
Pertinent Cardiovascular Imaging: TTE ___ revealed distal
anterior and apical akinesis; left ventricular ejection fraction
is 40-45%.
Physical Examination:
General: Awake, pleasant lying in bed, NAD
Neuro: Alert and oriented x4. Pleasant and cooperative. PERRLA
@3mm. Speech clear, appropriate and comprehensible. Tongue
midline, smile symmetric. Equal and strong hand grasps and foot
pushes.
HEENT: Neck supple, No JVD noted
CV: RRR, Normal S1 S2, or systolic/diastolic murmur
Lungs: Clear ___, posterior and anteriorly, non-labored. No use
of
accessory muscles noted.
Abdomen: soft, non-tender, + BS x4
PV: WWP, + pedal pulses, No edema, Palpable Pedal pulses ___.
Access sites: Right radial soft without bleeding or hematoma. +2
radial pulse. CSM WNL. Soft ecchymosis noted.
Pertinent Results:
Labs on Admission:
___ 02:50AM
WBC-10.2* Hgb-12.5 Hct-38.1 Plt ___ PTT-25.1 ___
Glucose-123* UreaN-22* Creat-0.8 Na-135 K-4.2 Cl-95* HCO3-24
AnGap-16
cTropnT-1.12*
proBNP-451*
CRP-0.5
Coronary angiogram (___):
Coronary Description
The coronary circulation is right dominant.
LM: The Left Main, arising from the left cusp, is a large
caliber vessel. This vessel bifurcates into the Left Anterior
Descending and Left Circumflex systems.
LAD: The Left Anterior Descending artery, which arises from the
LM, is a large caliber vessel.
The Diagonal, arising from the proximal segment, is a medium
caliber vessel.
Cx: The Circumflex artery, which arises from the LM, is a large
caliber vessel.
The ___ Obtuse Marginal, arising from the proximal segment, is a
medium caliber vessel.
The ___ Obtuse Marginal, arising from the mid segment, is a
medium caliber vessel.
RCA: The Right Coronary Artery, arising from the right cusp, is
a large caliber vessel.
The Right Posterior Descending Artery, arising from the distal
segment, is a medium caliber vessel.
The Right Posterolateral Artery, arising from the distal
segment, is a medium caliber vessel.
Interventional Details
Complications: There were no clinically significant
complications.
Findings
No angiographically apparent coronary artery disease.
TTE (___):
CONCLUSION:
The left atrial volume index is normal. There is normal left
ventricular wall thickness with a normal cavity size. There is
moderate regional left ventricular systolic dysfunction with
apical LV akinesis (see schematic). Overall left ventricular
systolic function is mildly depressed. The visually estimated
left ventricular ejection fraction is 40-45%. There is no
resting left ventricular outflow tract gradient. There is Grade
I diastolic dysfunction. Normal right ventricular cavity size
with normal free wall motion. The aortic sinus diameter is
normal for gender with normal ascending aorta diameter for
gender. The aortic arch diameter is normal with a normal
descending aorta diameter. The aortic valve leaflets (3) appear
structurally normal. There is no aortic valve stenosis. There is
no aortic regurgitation. The mitral valve leaflets appear
structurally normal with no mitral valve prolapse. There is
trivial mitral regurgitation. The pulmonic valve leaflets are
normal. The tricuspid valve leaflets appear structurally normal.
There is mild [1+] tricuspid regurgitation. The estimated
pulmonary artery systolic pressure is borderline elevated. There
is no pericardial effusion.
IMPRESSION: 1) Moderate focal in setting of mild global LV
systolic dysfunction suggestive of ___'s cardiomyopathy.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lubricating Drops (carboxymethylcellulose-glycern) 0.5-0.9 %
ophthalmic (eye) BID
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN fever, pain
2. Metoprolol Succinate XL 12.5 mg PO DAILY
3. Warfarin 5 mg PO DAILY16
Target INR ___. Lubricating Drops (carboxymethylcellulose-glycern) 0.5-0.9 %
ophthalmic (eye) BID
Discharge Disposition:
Home
Discharge Diagnosis:
___'s cardiomyopathy
Discharge Condition:
24-hour events:
Chest pain improved today. Low grades temps yesterday. Improved
with incentive spirometer use hourly. She was dizzy and
hypotensive yesterday requiring IV bolus of 250 cc and was not
able to get metoprolol or lisinopril as limited by blood
pressure. Her blood pressure was better this morning with SBP
greater than 100 and got 12.5 of metoprolol tartrate and 2.5 of
lisinopril. A few hours later she was slightly dizzy with blood
pressure 89/53. She was encouraged to increase p.o. fluids and
her dizziness resolved. She is now ambulating without any
symptoms.
Post-Procedure Day ___ s/p Cardiac Catheterization for ST
elevations; no obstructive CAD, no intervention
Subjective: "I am nervous to go home as I feel I am being
watched
closely here."
ROS: negative unless noted below
[X] CP
[] SOB
[] Pain
[X] Dizziness
[] Headache
[] Nausea/Vomiting
[] Decreased appetite
24-hour data:
___ 0734 Temp: 99.8 PO BP: 103/62 R Lying HR: 85 RR: 18
O2 sat: 93% O2 delivery: Ra
___ 0803 BP: 113/56 R Sitting HR: 83
___ 1312 BP: 89/53 R Sitting HR: ___ FSBG: ___ mild
___,
NP notified
___ PO Amt: 420ml
___ Urine Amt: 1575ml
Admit Weight: 61.4kg
Today's Weight: 62.5 kg
Tele: SR 60-80s, no arrhythmia alarms per telemetry review
LABS:
___ 06:11AM BLOOD WBC: 4.2 RBC: 3.41* Hgb: 10.4* Hct: 31.3*
MCV: 92 MCH: 30.5 MCHC: 33.2 RDW: 13.4 RDWSD: 45.___*
___ 06:11AM BLOOD ___: 16.4* PTT: 32.9 ___: 1.5*
___ 06:11AM BLOOD Glucose: 90 UreaN: 12 Creat: 0.7 Na: 135
K: 4.6 Cl: 100 HCO3: 25 AnGap: 10
___ 06:11AM BLOOD Calcium: 8.1* Phos: 2.7 Mg: 2.1
Pertinent Cardiovascular Imaging: TTE ___ revealed distal
anterior and apical akinesis; left ventricular ejection fraction
is 40-45%.
Physical Examination:
General: Awake, pleasant lying in bed, NAD
Neuro: Alert and oriented x4. Pleasant and cooperative. PERRLA
@3mm. Speech clear, appropriate and comprehensible. Tongue
midline, smile symmetric. Equal and strong hand grasps and foot
pushes.
HEENT: Neck supple, No JVD noted
CV: RRR, Normal S1 S2, or systolic/diastolic murmur
Lungs: Clear ___, posterior and anteriorly, non-labored. No use
of
accessory muscles noted.
Abdomen: soft, non-tender, + BS x4
PV: WWP, + pedal pulses, No edema, Palpable Pedal pulses ___.
Access sites: Right radial soft without bleeding or hematoma. +2
radial pulse. CSM WNL. Soft ecchymosis noted.
Current medications reviewed [x]
--------------- --------------- --------------- ---------------
--------------- --------------- --------------- ---------------
Active Inpatient Medication list as of ___ at 1424:
Medications - Standing
Sodium Chloride 0.9% Flush ___ mL IV Q8H and PRN, line flush
Lubricating Drops 0.5-0.9 % ophthalmic (eye) BID
Warfarin 5 mg PO/NG DAILY16
Metoprolol Succinate XL 12.5 mg PO DAILY
Medications - PRN
Acetaminophen 650 mg PO/NG Q6H:PRN fever, pain
Ramelteon 8 mg PO/NG QHS:PRN Insomnia
Senna 8.6 mg PO/NG BID:PRN Constipation - First Line
Polyethylene Glycol 17 g PO/NG DAILY:PRN Constipation - First
Line
--------------- --------------- --------------- ---------------
--------------- --------------- --------------- ---------------
Assessment: ___ with history osteoporosis, depression, anxiety,
who presented with chest pain, found to have ST elevations in
anterolateral leads s/p cath with no evidence of coronary artery
disease; TTE revealed Takotsubo cardiomyopathy. Her blood
pressures have been soft with mild dizziness requiring small IV
bolus yesterday of 250cc. This morning her SBP was greater than
100 and she was able to get 2.5 mg of lisinopril and 12.5 mg of
metoprolol tartrate. Within a few hours her blood pressure was
89/53 and she had mild dizziness. She increased her p.o. fluid
intake and her symptoms resolved. She is now ambulating without
any symptoms. As per Dr. ___ will send her home with
metoprolol only and stop the lisinopril. Also to note her
hemoglobin is 10.4 today with hematocrit 31.3 and platelets 133.
These have been down trending since starting on Lovenox, and
Coumadin. She has no evidence of bleeding.
Plan:
# Takotsubo Cardiomyopathy
- Medically manage
- Coumadin 5mg daily for apical akinesis (Goal INR ___ INR 1.5
today
- Stop lisinopril
- Metoprolol succinate 12.5 mg daily
- Encourage stress management upon discharge; defer to PCP for
resources and options; appointment requested
- CARDIOLOGY ___: Care to be established with Dr. ___
as scheduled
# Anemia: Hemoglobin 10.4, hematocrit 31.3, platelets 133; no
evidence of bleeding. This has been down trending since
admission in the setting of Lovenox and Coumadin.
-Continue Coumadin without bridge
-Stop Lovenox
-Repeat CBC on ___ at ___ when she is
they are having INR checked; results requested to go to
cardiologist and PCP
-___ was educated on signs and symptoms of bleeding and
was
instructed to seek urgent medical evaluation for any bleeding
# Chest Pain: Much improved today
- Tylenol PRN
# Family/HCP updated? Yes
Nutrition: Regular; ___ gm sodium /Heart healthy
Transitional:
-CBC to be checked on ___
-Follow up with Dr. ___ at ___
-Anticoagulation to be managed at ___ with Dr. ___
INR scheduled for ___.
Dispo: Discharge home without services
Anticipate:
[X] d/c home without services
[] d/c home with services
[] d/c to rehab/LTC
** Above plan reviewed and discussed with Dr. ___
** Above plan discussed with Ms. ___ who agrees. All questions
answered to patients satisfaction.
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Import Discharge Condition
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: History: ___ with CP// eval for intra-thoracic process
TECHNIQUE: Portable AP chest radiograph
COMPARISON: Chest radiographs ___
FINDINGS:
The lungs are well inflated and clear. No pleural effusion or pneumothorax.
Heart size is normal. The mediastinal contours are unremarkable. Surgical
clips again project over the mid to lower left lung. The inferolateral left
ribs are excluded from view.
IMPRESSION:
No acute cardiopulmonary abnormality.
Gender: F
Race: WHITE - EASTERN EUROPEAN
Arrive by UNKNOWN
Chief complaint: Chest pain, Lightheaded
Diagnosed with ST elevation (STEMI) myocardial infarction of unsp site
temperature: 97.0
heartrate: 70.0
resprate: 16.0
o2sat: 100.0
sbp: 105.0
dbp: 90.0
level of pain: 6
level of acuity: 2.0 | ___ with history osteoporosis, depression, anxiety,
who presented with chest pain that woke her up from sleep, found
to have ST elevations in anterolateral leads s/p cardiac
catheterization with no evidence of coronary artery disease; TTE
revealed Takotsubo cardiomyopathy. She admits to increased
anxiety in her life recently, but is unable to relate it to a
specific event. She continued to have chest pain with
inspiration over next ___ hours managed with Tylenol. She was
uncomfortable taking deep breathes and was limited by pain. That
pain has resolved. She also had low grade fever which improved
with aggressive pulmonary toileting, increased activity and use
of incentive spirometer. Her blood
pressures have been soft with mild dizziness requiring small NS
IV bolus yesterday of 250cc. This morning her SBP was greater
than 100 and she was able to get 2.5 mg of lisinopril and 12.5
mg of metoprolol tartrate per parameters. Within a few hours
her blood pressure was 89/53 and she had mild dizziness. She
increased her p.o. fluid intake and her symptoms resolved. She
is now ambulating without
any symptoms. As per Dr. ___ will send her home with
metoprolol succinate 12.5mg daily only and stop the lisinopril.
Also to note her hemoglobin is 10.4 today with hematocrit 31.3
and platelets 133. These have been down trending since starting
on Lovenox and Coumadin. The Lovenox was discontinued and she
will continue on Coumadin 5mg daily and have INR checked on
___. Her INR was 1.5 today and will not be
bridged per Dr. ___ due to concerns of her down trending H/H
and platelets. She will also have a CBC checked that same day
with results to Dr. ___ PCP. She has no evidence of
bleeding. She will ___ with her PCP as scheduled and was
encouraged to consider stress management options. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics)
Attending: ___
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ year old female with COPD, DM, sarcoid, and HLD presents with
chest pain for the past three to five days. The pain is
central/left sided in distribution, and hurts with inhaling.
The patient reports no dyspnea. She reports feeling better when
sitting up. The patient was resting when the pain started most
recently a few days ago. There is no fevers/chills, no N/V, no
abd pain, no D/C. There have been no sick contacts. About 3
weeks ago the patient had similar chest pain. She also had
runny nose, cough, headache, and sore throat. The upper
respiratory symptoms resolved except for ongoing mild cough.
The chest pain also resolved after ~2 days until ~5 days ago
when it recurred and worsened.
In the ED, initial vitals were 99 128/58 32 78%RA. Patient was
placed on a non-rebreather and improved with this and
nebulizers. ECG showed ST changes in the inferior leads.
Patient received aspirin 325 mg x 1. Troponin was negative x 2.
Bedside ultrasound showed no perdicardial effusion or notable
wall motion abnormality. Chem7 was unremarkable. CBC showed
elevated WBC count to 12.2K, no left shift. proBNP was 625.
Lactate was 1.8. D-dimer was elevated, and CTA chest showed no
pulmonary embolism on preliminary read. Flu swab was obtained
given tachypnea and hypoxia. Cardiology was consulted and
thought the ECG and TTE did not represent ischemia, more likely
pericarditis. They recommended 500 mg additional aspirin and
colchicine. She triggered for heart rate while awaiting
placement with atrial fibrillation with RVR in the 140s-150s,
and systolic blood pressure in the ___. Diltiazem 10 mg x
1 was given. Patient was given 60 mg prednisone, concurrent
with her home dose.
On review of systems, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. She denies recent fevers or rigors. She
denies exertional buttock or calf pain. All of the other review
of systems were negative.
+ recent chills
+ loose stool x 3 three days ago
Cardiac review of systems is notable for absence of current
chest pain (much better now than in the ED), dyspnea on
exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: (-) Diabetes, (-) Dyslipidemia, (+)
Hypertension
2. CARDIAC HISTORY:
None
3. OTHER PAST MEDICAL HISTORY:
COPD
Asthma
Gastric ulcer
Sarcoidosis
Tobacco abuse, quit smoking 2 weeks ago
Social History:
___
Family History:
sister has "enlarged heart"
Physical Exam:
ADMISSION:
VS: 97.9, 106/57, 68, 20, 96% 2L
Gen: pleasant, NAD
HEENT: no conjunctival pallor, mmm, OP clear
Neck: supple, ormal carotid upstroke without bruits.
Chest: lungs with crackles present at the bases bilaterally.
CV: RRR, nl S1,S2, No murmurs, rubs, or gallops
Abdomen: soft, NT, ND, BS+
Extremities: wwp, 2+ pulses bilaterally. Trace ___ edema.
Skin: no rashes, ecchymoses.
Neuro: A&Ox3. CN II-XII grossly intact. Strength ___ bilaterally
.
DISCHARGE:
VS: 98.0/98.0, 98/59 (93/54-106/57), 63-68, 20, 98% 2L => 95% on
RA
Wt: 77.3kg
Gen: pleasant, NAD
HEENT: no conjunctival pallor, mmm, OP clear
Neck: supple, normal carotid upstroke without bruits.
Chest: lungs with crackles present at the bases bilaterally.
CV: RRR, nl S1,S2, No murmurs, rubs, or gallops
Abdomen: soft, NT, ND, BS+
Extremities: wwp, 2+ pulses bilaterally. Trace ___ edema.
Skin: no rashes, ecchymoses.
Neuro: A&Ox3. CN II-XII grossly intact.
Pertinent Results:
___ 08:30AM BLOOD WBC-12.2* RBC-4.88 Hgb-14.5 Hct-45.0
MCV-92 MCH-29.8 MCHC-32.2 RDW-14.1 Plt ___
___ 08:30AM BLOOD Neuts-62.8 ___ Monos-4.3 Eos-2.9
Baso-0.9
___ 08:30AM BLOOD WBC-13.3* RBC-4.32 Hgb-12.7 Hct-39.9
MCV-92 MCH-29.4 MCHC-31.8 RDW-13.7 Plt ___
___ 08:30AM BLOOD ___ PTT-150* ___
___ 10:20AM BLOOD Glucose-79 UreaN-11 Creat-1.0 Na-142
K-4.0 Cl-105 HCO3-26 AnGap-15
___ 08:30AM BLOOD CK(CPK)-73
___ 08:30AM BLOOD proBNP-625*
___ 08:30AM BLOOD cTropnT-0.01
___ 02:45PM BLOOD cTropnT-<0.01
___ 08:30AM BLOOD CK-MB-3 cTropnT-<0.01
___ 08:30AM BLOOD Calcium-9.3 Phos-3.4 Mg-2.1
___ 08:30AM BLOOD D-Dimer-1438*
___ 02:45PM BLOOD TSH-3.0
___ 09:08AM BLOOD Lactate-1.8
___ 03:00PM URINE Color-Yellow Appear-Hazy Sp ___
___ 03:00PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-LG
___ 03:00PM URINE RBC-1 WBC-10* Bacteri-FEW Yeast-NONE
Epi-37
.
MICRO:
___ -- blood culture x 2 pending
___ -- Influenza A/B by ___
Source: Nasopharyngeal aspirate.
DIRECT INFLUENZA A ANTIGEN TEST (Final ___:
Less than 60 columnar epithelial cells;.
Specimen inadequate for detecting respiratory viral
infection by ___ testing.
DIRECT INFLUENZA B ANTIGEN TEST (Final ___:
Less than 60 columnar epithelial cells;.
Specimen inadequate for detecting respiratory viral
infection by ___ testing.
.
EKGs ___ (as per cardiology consult in ED): Initially SR
with STE in the inferior leads with PR depression, additional
non-specific ST and T changes. Then AF with RVR and
non-specific ST and T changes. Then SR with atrial and
ventricular ectopy and non-specific ST and T changes.
.
2D-ECHOCARDIOGRAM ___:
Conclusions
The left atrium is normal in size. The interatrial septum is
aneurysmal. No atrial septal defect is seen by 2D or color
Doppler. The estimated right atrial pressure is ___ mmHg. Left
ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%). The estimated cardiac
index is normal (>=2.5L/min/m2). The right ventricular cavity is
mildly dilated with normal free wall contractility. [Intrinsic
right ventricular systolic function is likely more depressed
given the severity of tricuspid regurgitation.] The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis or aortic regurgitation. The
mitral valve leaflets are structurally normal. Mild (1+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. Moderate [2+] tricuspid regurgitation is seen. There
is moderate to severe pulmonary artery systolic hypertension.
There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. Normal biventricular
cavity sizes with preserved regional and global systolic
function. Right ventricular cavity dilation with preserved free
wall motion. Moderate to severe pulmonary artery hypertension.
Moderate tricuspid regurgitation.
Compared with the prior study (images reviewed) of ___, the
right ventricular cavity is now slightly larger and the severity
of tricuspid regurgitation has slightly increased. The other
findings are similar.
.
CTA CHEST ___:
1. There is no evidence of PE or aortic dissection.
2. Bibasilar atelectasis and emphysematous changes bilaterally,
worse since the comparison study.
3. Prominent main pulmonary artery may be due to a component of
pulmonary hypertension.
4. Enlarged hilar and mediastinal lymph nodes are more prominent
and may relate to patient's history of sarcoidosis.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Furosemide 60 mg PO DAILY
3. Potassium Chloride 40 mEq PO DAILY Duration: 24 Hours
Hold for K > 5
4. Albuterol Inhaler 2 PUFF IH Q4H:PRN dyspnea, wheezing
5. Fluticasone Propionate 110mcg 2 PUFF IH BID
6. Ipratropium Bromide MDI 2 PUFF IH QID
7. Ipratropium Bromide Neb 1 NEB IH Q6H dyspnea, wheezing
8. PredniSONE 2.5 mg PO DAILY
9. Vitamin B Complex 1 CAP PO DAILY
10. Omeprazole 20 mg PO DAILY
11. Vitamin E 200 UNIT PO DAILY
12. Desonide 0.05% Cream 1 Appl TP DAILY
13. Fluocinonide 0.05% Ointment 1 Appl TP BID
14. Sulfacetamide 10% Ophth Soln. ___ DROP BOTH EYES Frequency
is Unknown
15. Tobramycin 0.3% Ophth Ointment 1 Appl BOTH EYES BID
16. MetRONIDAZOLE (FLagyl) 500 mg PO BID
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN dyspnea, wheezing
2. Aspirin 325 mg PO DAILY
RX *aspirin 325 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
3. Fluticasone Propionate 110mcg 2 PUFF IH BID
4. Furosemide 60 mg PO DAILY
5. Ipratropium Bromide MDI 2 PUFF IH QID
6. Ipratropium Bromide Neb 1 NEB IH Q6H dyspnea, wheezing
7. MetRONIDAZOLE (FLagyl) 500 mg PO BID
8. Omeprazole 40 mg PO DAILY
RX *omeprazole 40 mg 1 capsule(s) by mouth daily Disp #*7
Capsule Refills:*0
9. Potassium Chloride 40 mEq PO DAILY Duration: 24 Hours
Hold for K > 5
10. PredniSONE 2.5 mg PO DAILY
11. Sulfacetamide 10% Ophth Soln. ___ DROP BOTH EYES Frequency
is Unknown
12. Tobramycin 0.3% Ophth Ointment 1 Appl BOTH EYES BID
13. Vitamin B Complex 1 CAP PO DAILY
14. Ibuprofen 800 mg PO Q8H Duration: 7 Days
RX *ibuprofen 800 mg 1 tablet(s) by mouth three times a day Disp
#*21 Tablet Refills:*0
15. Desonide 0.05% Cream 1 Appl TP DAILY
16. Fluocinonide 0.05% Ointment 1 Appl TP BID
17. Vitamin E 200 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
chest pain
possible pericarditis
hypoxia
chronic obstructive pulmonary disease (COPD)
sarcoidosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Shortness of breath and hypoxia. Evaluate for infectious process
versus fluid.
TECHNIQUE: Semi-upright AP frontal radiographs of the chest.
COMPARISON: Multiple prior radiographs of the chest, most recent ___.
FINDINGS:
The patient is rotated to the right significantly limiting evaluation of the
mediastinal structures. Allowing for these limitations a faint small focal
opacity in the left upper lobe is not appreciably changed since ___
and may correspond to scarring. Bibasilar hazy opacities are likely due to
atelectasis, however small pleural effusions cannot be excluded on this
limited frontal radiograph, and there is mild blunting of the lateral
costophrenic sulci. The mediastinal structures are not well evaluated,
however, the heart appears mildly enlarged. There is no evidence of
pulmonary edema or pneumothorax.
IMPRESSION:
1. Bibasilar opacities likely a combination of atelectasis and possibly trace
pleural effusions.
2. If clinically indicated a repeat frontal and lateral radiograph with normal
positioning would provide a more complete evaluation.
Radiology Report
HISTORY: Chest pain, new atrial fibrillation. Evaluate for PE or aortic
dissection.
TECHNIQUE: Helical MDCT images were obtained through the chest after
administration of 100 cc of Omnipaque IV contrast. Multiplanar axial,
coronal, and sagittal images were generated and reviewed.
COMPARISON: CT chest ___.
FINDINGS:
CT thorax: Although this study is not designed to evaluate the
intra-abdominal structures, the visualized solid organs are grossly
unremarkable.
The thyroid is unremarkable and there is no supraclavicular or axillary lymph
node enlargement. The airways are patent at the subsegmental level. Hilar
and mediastinal lymphadenopathy is more prominent: 1.4 cm right lower
paratracheal lymph node (3: 83), 3 x 2.7 cm subcarinal lymph node (3:96). The
pericardium, and great vessels are within normal limits. Lung windows
demonstrate bilateral emphysematous changes worse since the prior study.
There is bibasilar atelectasis. There is no pleural effusion or pneumothorax.
CTA thorax: The aorta and major vessels are well opacified. The aorta is of
normal caliber throughout the thorax without intramural hematoma, aneurysm, or
dissection. The main pulmonary artery is somewhat prominent suggesting a
component of pulmonary hypertension. The pulmonary arteries are opacified to
the subsegmental level. There is no filling defect in the main, right, left,
lobar or subsegmental pulmonary arteries.
Osseous structures: There is no focal osseous lesion concerning for
malignancy.
IMPRESSION:
1. There is no evidence of PE or aortic dissection.
2. Bibasilar atelectasis and emphysematous changes bilaterally, worse since
the comparison study.
3. Prominent main pulmonary artery may be due to a component of pulmonary
hypertension.
4. Enlarged hilar and mediastinal lymph nodes are more prominent and may
relate to patient's history of sarcoidosis.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: CP
Diagnosed with PERICARDIAL DISEASE NOS, HYPERTENSION NOS, SARCOIDOSIS
temperature: nan
heartrate: 99.0
resprate: 32.0
o2sat: 78.0
sbp: 128.0
dbp: 58.0
level of pain: 8
level of acuity: 1.0 | ___ yo woman with a PMH of COPD, active tobacco use, sarcoidosis,
and HTN presented with chest pain and AF and found to be
hypoxic.
# Chest pain: Her chest pain could be consistent with
pericarditis or MSK pain. CAD is very unlikely as she has had
prolonged pain with normal cardiac enzymes and echo, with an
alternative diagnosis much more likely. We initiated treatment
of pericarditis with ibuprofen for 7 days. Omeprazole was
increased from 20 to 40mg daily, given hx of gastric ulcer and
current NSAID use.
# Hypoxia: Most likely due to underlying lung disease
(sarcoidosis and COPD) with likely poor medication compliance
(pt told nurses she didn't need her medications if she's feeling
well). Suspicion for flu is low, and flu swab from ED did not
have sufficient sample. ___ walked with her and flet that she
was safe for discharge home without home O2; she only
desaturated to less than 91% on room air when walking up stairs
. She was strongly encouraged to stop smoking. She was set up
with pulmonary follow up. Home medications were continued.
# AF: This may have been triggered by hypoxia or pericarditis.
Heparin was started in the ED. Dilt drip was also started in
ED, but stopped when patient became hypotensive. Patient
converted to sinus and stayed in sinus. CHADS2 is ___. Heparin
was stopped. Aspirin was switched from 81mg daily to 325mg
daily. Decision to anticoagulate or to initiate beta blocker or
CCB can be revisited if patient presents in afib again or when
patient sees her PCP for follow up. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Novocain / lidocaine
Attending: ___.
Chief Complaint:
headache
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ M to F transgender, borderline personality d/o, bipolar d/o,
hx of multiple foreign body ingestions currently on treatment
for pneumonia with levofloxacin presents with persistent
headache.
She was recently admitted ___ with complaints of
headache, neck pain and fevers. She was diagnosed with HCAP,
started on vancomycin/cefepime and transitioned to levofloxacin.
Because of neck stiffness, she underwent an LP which revealed a
WBC 1, normal protein, and normal glucose levels. Her neck
stiffness was attributed to MSK etiology and her pain managed
with oxycodone and morphine as needed.
She returned to the ED ___ with complaints of dizziness and
headache. She was diagnosed with post-LP HA after it was noted
to be positional and better when laying flat. She was discharged
from the ED after symptomatic control. She went to her PCPs
office ___ with persistent severe HA. Because of the
positional nature of the HA and that it had not improved, she
was referred to the ED for further management.
In the ED, initial vitals were:
98.9 67 126/90 18 98% ra
Patient was given 1 L NS, fiorcet, zofran, and oxycodone with no
relief. Pain service was consulted for epidural blood patch and
will see patient in the morning.
On the floor, she reports that the headache is better in the
dark with sunglasses. She is still having a lot of nausea,
occasional emesis. She is wondering if this is related to any
ingestions. She reports her last ingestion was in ___ because
she got in a fight with her roommate. The HA is also better when
she is flat in bed. She has also noted dizziness, mild gait
instability, and poor PO appetite. She also has neck pain.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies sinus tenderness, rhinorrhea or congestion. Denies
cough, shortness of breath. Denies chest pain or tightness,
palpitations. Denies nausea, vomiting, diarrhea, constipation or
abdominal pain. No recent change in bowel or bladder habits. No
dysuria. Denies arthralgias or myalgias.
Past Medical History:
PAST MEDICAL & SURGICAL HISTORY:
- Osteomyelitis of right ankle
- Right ankle fracture s/p ORIF in ___
- Alcohol abuse
- Bipolar disorder
- Depression
- Multiple suicide attempts and foreign body ingestions
- Borderline personality disorder
- Post-operative trans-gender (Male to Female)
Social History:
___
Family History:
FAMILY HISTORY:
Esophageal cancer in father
Physical Exam:
ADMISSION PHYSICAL EXAM:
vitals: 98.5 97/42 61 18 95%RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: +brudzinskis, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, diffusely TTP, bowel sounds present, no rebound
tenderness or guarding, no organomegaly
Ext: TTP along cervical spine and lumbar spine, warm, well
perfused, 2+ pulses, no clubbing, cyanosis or edema
Skin: intact no rash
Neuro: CN II-XII intact, ___ strength in UE and ___
DISCHARGE PHYSICAL EXAM:
Vital Signs: 98 108/64 101 18 96 RA
General: Alert, oriented, comfortable appearing.
HEENT: Sclera anicteric, MMM, oropharynx clear. No photophobia
today.
NECK: Range of motion significantly limited by pain. Overall
fullness to neck but no discrete LAD. Tender to palpation of the
supraclavicular areas bilaterally, over SCMs, and over posterior
neck. Tender of cervical spinous processes.
Back: Tender at site of LP. No surorunding erythema fluctuance
or warmth.
Lungs: CTAB
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: Tender diffusely, soft, nondistended, bowel sounds
present.
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: Without rashes or lesions
Neuro: A/Ox3. PERRL. +photophobia.
Pertinent Results:
ADMISSION LABS
___ 10:30PM PLT COUNT-342
___ 10:30PM NEUTS-68.0 ___ MONOS-8.6 EOS-2.1
BASOS-0.7 IM ___ AbsNeut-7.28* AbsLymp-2.13 AbsMono-0.92*
AbsEos-0.22 AbsBaso-0.08
___ 10:30PM WBC-10.7* RBC-3.92 HGB-11.3 HCT-34.8 MCV-89
MCH-28.8 MCHC-32.5 RDW-13.4 RDWSD-43.5
___ 10:30PM GLUCOSE-92 UREA N-14 CREAT-1.0 SODIUM-135
POTASSIUM-4.4 CHLORIDE-99 TOTAL CO2-24 ANION GAP-16
DISCHARGE LABS
___ 03:48PM PLT COUNT-332
___ 03:48PM NEUTS-74.8* LYMPHS-15.2* MONOS-6.7 EOS-2.0
BASOS-0.6 IM ___ AbsNeut-8.16* AbsLymp-1.66 AbsMono-0.73
AbsEos-0.22 AbsBaso-0.07
___ 03:48PM WBC-10.9* RBC-3.95 HGB-11.4 HCT-35.1 MCV-89
MCH-28.9 MCHC-32.5 RDW-13.3 RDWSD-43.3
___ 03:48PM GLUCOSE-88 UREA N-10 CREAT-0.9 SODIUM-134
POTASSIUM-4.7 CHLORIDE-100 TOTAL CO2-21* ANION GAP-18
IMAGING:
KUB ___
Metallic foreign objects visualized within the cecum.
Non-obstructive bowel
gas pattern.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Levofloxacin 750 mg PO Q24H
2. Estrogens Conjugated 5 mg PO DAILY
3. Spironolactone 200 mg PO DAILY
4. Senna 8.6 mg PO BID
5. Polyethylene Glycol 17 g PO DAILY:PRN constipation
Discharge Medications:
1. Estrogens Conjugated 5 mg PO DAILY
2. Levofloxacin 750 mg PO Q24H
3. Polyethylene Glycol 17 g PO DAILY:PRN constipation
4. Senna 8.6 mg PO BID
5. Spironolactone 200 mg PO DAILY
6. Acetaminophen-Caff-Butalbital ___ TAB PO Q8H:PRN HEADACHE
RX *butalbital-acetaminophen-caff 50 mg-300 mg-40 mg 1
capsule(s) by mouth every 8 hours Disp #*15 Capsule Refills:*0
7. Cyclobenzaprine 10 mg PO BID:PRN neck pain
RX *cyclobenzaprine 10 mg 1 tablet(s) by mouth twice daily Disp
#*10 Tablet Refills:*0
8. HYDROmorphone (Dilaudid) 4 mg PO Q6H:PRN PAIN
RX *hydromorphone 4 mg 1 tablet(s) by mouth every 6 hours Disp
#*4 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnoses: post-lumbar puncture headache
Secondary diagnoses: pneumonia, bipolar disorder, depression,
history of alcohol abuse
Discharge Condition:
Mental Status: Clear and coherent.
Activity Status: Ambulatory - Independent.
Level of Consciousness: Alert and interactive.
Followup Instructions:
___
Radiology Report
INDICATION: ___ year old woman with hx of ingestion // more ingestions
TECHNIQUE: Supine and upright frontal abdominal radiographs were obtained.
COMPARISON: Abdominal radiographs dated ___.
FINDINGS:
The metallic foreign objects are visualized within the cecum. There are
barium filled diverticula in the left lower quadrant. The bowel gas pattern
is unremarkable with gas seen in nondistended loops of large and small bowel.
There is no evidence of ileus or obstruction. There is no evidence of
intraperitoneal free air. The bony structures are unremarkable.
IMPRESSION:
Metallic foreign objects visualized within the cecum. Non-obstructive bowel
gas pattern.
Gender: F
Race: WHITE
Arrive by WALK IN
WALK IN
Chief complaint: Headache
Headache, Dizziness
Diagnosed with HEADACHE
LUMBAR PUNCTURE REACTION, ABN REACT-FLUID ASPIRAT
temperature: 98.9
97.9
heartrate: 67.0
73.0
resprate: 18.0
18.0
o2sat: 98.0
98.0
sbp: 126.0
122.0
dbp: 90.0
75.0
level of pain: 9
9
level of acuity: 3.0
3.0 | Ms. ___ is a ___ year old transgender M to F with a history
of borderline personality disorder, bipolar disorder and
multiple prior suicide attempts who was recently discharged from
___ ___ after she presented with fever and neck stiffness,
was found to have HCAP PNA, and had a negative LP. She was
readmitted with post-LP headache. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Latex
Attending: ___.
Chief Complaint:
chest pain, abnormal stress
Major Surgical or Invasive Procedure:
Cardiac catheterization ___
History of Present Illness:
___ year old woman with IDDM and hypertension who presents with 2
weeks of exertional and rest chest pain.
For the past 2 weeks she's had pain/pressure in her chest that
radiates mostly to her left arm (sometimes to the right) with
radiation to her left neck and jaw as well. She has had
right-sided chest pain which is sharp, located at the mid right
rib cage, has been going on for 1 month, and is worse with
breathing or taking deep breaths. Her second chest pain is a
tight to sharp mid chest pain under her sternum, which occurs
when she walks around or tries to climb stairs, and is
associated
with shortness of breath. Given worsening nature and more
frequent symptoms she presented to the ED.
She denies any major bleeding issues. Sometimes notices blood
tinged toilet paper after BM's with probable hemorrhoids.
Patient underwent an exercise stress test in the ED which was
stopped after 3 minutes (estimated peak MET capacity of 2.4) due
to her feeling lightheaded/dizzy with her report of chest pain
as
well. Formal report notes she did not experience chest pain
though mentions progressive dizziness during exercise which
resolved during early recovery. Upon evaluation by the
cardiology
fellow in the ED, patient was chest pain free.
In the ED initial vitals were: 96.5 76 148/87 18 97% RA
Exam notable for: bibasilar crackles, no murmur, soft abdomen,
no leg swelling, no CVA tenderness
Labs notable for:
1. BMP: Na 136 K 4.6 Cl 97 Bicarb 28 BUN 14 Cr 0.8 Glu 255
2. CBC: wbc 6.3 hgb 11.5 plt 230
3. d dimer 271
4. trop <0.01 x
5. bnp 28
Images notable for: CXR No acute process
EKG: (PER ED DASH) EKG is sinus at 84, normal axis, normal
intervals, there is a 1 mm J-point elevation in V2, this is
isolated, there are no other ST changes, there are no ischemic
appearing T-wave inversions, there is no prior available for
comparison.
Patient was given:
metop 12.5, aspirin 81 mg, atorva 10, 1L NS, insulin as per
___ recs, Levothyroxine 150mcg, fluoxetine 40mg, trazadone
25mg
On the floor patient denies any chest pain or shortness of
breath
or dizziness. Notes that symptoms only occur with exertion and
have been worsening over the past 2 weeks though present over
the
past 6 months. Exertional chest pain and dyspnea with pleuritic
chest pain in the right lower chest. Chest pain/shortness of
breath and dizziness have never occurred at rest. Denies
fevers/chills, cough, periods of stasis, abdominal pain,
hematuria, melena.
Past Medical History:
1. CARDIAC RISK FACTORS
- poorly controlled insulin-dependent diabetes with HbA1c of 18
c/b neuropathy
- hypertension
- hyperlipidemia
2. OTHER MEDICAL HISTORY
hypothyroidism (s/p total thyroidectomy ___ thyroid CA, on
replacement)
HTN
HLD
Depression/anxiety
Ovarian cysts
Social History:
___
Family History:
Father- diabetes, heart disease
Mother- diabetes
MGM, ___, borther- DM
Sister- HTN
Physical ___:
ADDMISION PHYSICAL EXAMINATION:
V: 98.3 PO BP 119 / 74R Sitting 77 20 Sat96%RA
GENERAL: Well developed, well nourished in NAD. Oriented x3.
HEENT: Sclera anicteric. PERRL. EOMI. No pallor or cyanosis of
the oral mucosa. No xanthelasma.
NECK: Supple. JVP of 8 cm at 45 degrees
CARDIAC: regular rate and rhythm. Normal S1, S2. No murmurs,
rubs, or gallops.
LUNGS: No chest wall deformities or tenderness. Respiration is
unlabored with no accessory muscle use. No crackles, wheezes or
rhonchi.
ABDOMEN: Soft, non-tender, non-distended.
EXTREMITIES: Warm, well perfused. no peripheral edema.
PULSES: Distal and radial palpable and symmetric.
Psych: full affect, denies SI/HI
DISCHARGE PHYSICAL EXAMINATION:
VS: 24 HR Data (last updated ___ @ 653)
Temp: 98.9 (Tm 98.9), BP: 96/56 (79-106/43-67), HR: 78
(78-95), RR: 16 (___), O2 sat: 94% (93-99), O2 delivery: Ra,
Wt: 112.87 lb/51.2 kg
GENERAL: Well developed, well nourished in NAD. Oriented x3.
HEENT: Sclera anicteric. PERRL. EOMI. No pallor or cyanosis of
the oral mucosa. No xanthelasma.
NECK: Supple. JVP not elevated
CARDIAC: regular rate and rhythm. Normal S1, S2. No murmurs,
rubs, or gallops.
LUNGS: CTAB, no m/r/g
ABDOMEN: Soft, non-tender, non-distended.
EXTREMITIES: Warm, well perfused. no peripheral edema.
PULSES: Distal and radial palpable and symmetric.
Psych: full affect, denies SI/HI
Pertinent Results:
ADMISSION LABS
===============
___ 11:55AM BLOOD WBC-6.4 RBC-4.46 Hgb-11.0* Hct-32.4*
MCV-73* MCH-24.7* MCHC-34.0 RDW-14.4 RDWSD-37.4 Plt ___
___ 11:55AM BLOOD Neuts-61.2 ___ Monos-7.1 Eos-0.2*
Baso-0.5 Im ___ AbsNeut-3.89 AbsLymp-1.95 AbsMono-0.45
AbsEos-0.01* AbsBaso-0.03
___ 11:55AM BLOOD ___ PTT-27.0 ___
___ 11:55AM BLOOD Glucose-417* UreaN-9 Creat-0.7 Na-131*
K-4.4 Cl-92* HCO3-26 AnGap-13
___ 11:55AM BLOOD ALT-22 AST-25 AlkPhos-94 TotBili-0.2
___ 11:55AM BLOOD proBNP-28
___ 11:55AM BLOOD cTropnT-<0.01
___ 06:22PM BLOOD cTropnT-<0.01
___ 12:00PM BLOOD ___ pO2-36* pCO2-47* pH-7.41
calTCO2-31* Base XS-3
INTERVAL LABS
===============
___ 04:45AM BLOOD calTIBC-241* Ferritn-61 TRF-185*
___ 04:45AM BLOOD Triglyc-147 HDL-94 CHOL/HD-2.3 LDLcalc-89
___ 04:45AM BLOOD TSH-62*
___ 04:45AM BLOOD Free T4-0.4*
DISCHARGE LABS
================
___ 07:00AM BLOOD WBC-7.6 RBC-4.33 Hgb-10.6* Hct-31.8*
MCV-73* MCH-24.5* MCHC-33.3 RDW-14.7 RDWSD-39.3 Plt ___
___ 07:00AM BLOOD Glucose-171* UreaN-16 Creat-0.7 Na-134*
K-4.0 Cl-100 HCO3-25 AnGap-9*
STUDIES/IMAGING
===============
___ CXR
No acute intrathoracic process.
___ Stress Test
INTERPRETATION: This ___ yo woman with h/o HTN, HLD, and poorly
controlled IDDM was referred to the lab from the ED following
negative
serial cardiac enzymes for evaluation of chest discomfort. The
patient
exercised for 2.9 minutes of a Modified ___ protocol and was
stopped
at the patient's request for fatigue and dizziness. The
estimated peak
MET capacity was 2.4, which represents a poor exercise tolerance
for her
age. There were no reports of chest, back, neck, or arm
discomforts
during the study. The patient noted progressive dizziness during
exercise which resolved during early recovery. There were no
significant
ST changes noted during exercise or recovery. Rhythm was sinus
with no
ectopy. There was an appropriate heart rate and blood pressure
response
to the achieved workload. Normal blood sugar recorded
post-exercise of
210 mg/dl.
IMPRESSION: Poor functional capacity with dizziness as noted. No
anginal
type symptoms or ischemic EKG changes. Appropriate hemodynamic
response
to low workload.
___ TTE
The left atrial volume index is normal. No atrial septal defect
is seen by 2D or color Doppler. The estimated right atrial
pressure is ___ mmHg. The interatrial septum is bowed to the
right suggesting high left atrial pressures. Left ventricular
wall thickness, cavity size and regional/global systolic
function are normal (LVEF >55%). Right ventricular chamber size
and free wall motion are normal. The diameters of aorta at the
sinus, ascending and arch levels are normal. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Trivial mitral regurgitation is seen. The estimated
pulmonary artery systolic pressure is normal. There is a
trivial/physiologic pericardial effusion.
IMPRESSION: Normal left ventricular wall thickness, cavity size,
and regional/global systolic function. Mild tricuspid
regurgitation.
___ Coronary Cath
Coronary Anatomy
Dominance: Right
* Left Main Coronary Artery
The LMCA is without significant disease.
* Left Anterior Descending
The LAD is with mild diffuse disease.
* Circumflex
The Circumflex is with mild diffuse proximal disease.
The ___ Marginal is without significant disease.
* Right Coronary Artery
The RCA is with 30% proximal.
The Right PDA is without significant disease.
MICROBIOLOGY
=============
Urine cultures negative
Blood cultures pending at time of discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 10 mg PO DAILY
2. MetFORMIN (Glucophage) 1000 mg PO BID
3. Atorvastatin 10 mg PO QPM
4. Aspirin 81 mg PO DAILY
5. FLUoxetine 40 mg PO DAILY
6. Levothyroxine Sodium 150 mcg PO DAILY
7. TraZODone 25 mg PO QHS:PRN insomnia
8. Glargine 30 Units Breakfast
Glargine 30 Units Bedtime
Humalog 10 Units Breakfast
Humalog 10 Units Lunch
Humalog 10 Units Dinner
Discharge Medications:
1. Glargine 25 Units Dinner
Novolog 9 Units Breakfast
Novolog 8 Units Lunch
Novolog 8 Units Dinner
Insulin SC Sliding Scale using Novolog Insulin
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 10 mg PO QPM
4. FLUoxetine 40 mg PO DAILY
5. Levothyroxine Sodium 150 mcg PO DAILY
6. MetFORMIN (Glucophage) 1000 mg PO BID
7. TraZODone 25 mg PO QHS:PRN insomnia
8. HELD- Lisinopril 10 mg PO DAILY This medication was held. Do
not restart Lisinopril until your PCP tells you to restart
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Hypothyroidism
IDDM
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ with retrosternal CP// Eval for PNA, acute process
COMPARISON: ___
FINDINGS:
PA and lateral views of the chest provided.
There is no focal consolidation, effusion, or pneumothorax. The
cardiomediastinal silhouette is normal. Imaged osseous structures are intact.
No free air below the right hemidiaphragm is seen.
IMPRESSION:
No acute intrathoracic process.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Chest pain, Hyperglycemia
Diagnosed with Chest pain, unspecified, Type 1 diabetes mellitus with hyperglycemia, Long term (current) use of insulin
temperature: 96.5
heartrate: 76.0
resprate: 18.0
o2sat: 97.0
sbp: 148.0
dbp: 87.0
level of pain: 8
level of acuity: 2.0 | ___ year old female with IDDM and thyroid cancer s/p
thyroidectomy presented with exertional CP and SOB, found to
have clean coronaries on cardiac cath, however functionally
hypothyroid with elevated TSH likely due to non compliance of
medications.
ACTIVE ISSUES
==============
# Chest pain
# SOB
The patient presented with several months chest pain and dyspnea
on exertion that per the patient had been progressive and
acutely worse in past few weeks. The symptoms were at first
concerning for unstable angina, and the patient underwent a
stress test in the ED, which was inconclusive because the
patient did not tolerate exercise due to symptoms. The patient
was sent to the cath lab to evaluate coronaries, which revealed
non obstructive CAD. As such, the patient's symptoms were
attributed to profound hypothyroidism as below. Furthermore, she
is somewhat of a poor historian and upon further questioning, it
was not clear that the patient was having exertional chest pain
prior to her presentation. She was continued on asprin 81mg
daily. She was initially given metoprolol and home lisinopril
for presumed CAD, however these were discontinued for
hypotension and given that there was no strong indication. She
was continued on home atorvastatin 10mg as lipid panel was found
to be within acceptable range.
# Hypothyroidism
The patient has a history of thyroid cancer s/p thyroidectomy
now on replacement levothyroxine at home. Her TSH was found to
be markedly elevated at 62 and free T4 of 0.4, suggesting likely
poor medication compliance. It was felt that her functional
hypothyroidism was likely a major contributor to fatigue and
exertional dyspnea. She was continued on home levothyroxine and
endocrinology was consulted and recommended continuing current
dose of thyroid replacement therapy.
# Hypotension
The patient was noted to be hypotensive throughout admission.
Likely multifactorial in the setting of hypothyroidism, NPO for
cardiac cath, and administration of lisinopril and metoprolol.
While lisinopril was a listed home med, it was likely that she
was not taking it previously. Metoprolol and lisinopril were
discontinued and the patient was given IV fluids to good effect.
She was ambulating without symptoms and blood pressures were
stable prior to discharge.
# Diabetes, (HgbA1C 18% ___
The patient presented with glucosuria and ketones though VBG
with normal pH. Her last A1c was very high at 18%. The patient
admitted that she stopped her insulin 2 weeks ago, and has been
using it inconsistently for months. Her home metformin was held
while inpatient. ___ was consulted and assisted in managing
insulin regimen. They recommended continuing with 25u Lantus at
dinnertime, Novalog fixed doses of 8u with breakfast, 8u at
lunch, and 7u at dinner, in addition to an insulin sliding
scale. She was seen by the diabetes educator nurse to reinforce
the importance of compliance with insulin regimen. A follow up
appointment with ___ is also being arranged for continued
care.
CHRONIC ISSUES:
==============
# HTN:
Has been hypotensive this admission. No antihypertensive agents
were
needed at this time.
# HLD:
She was continued on atorvastatin 10mg.
# Depression:
The patient endorsed no SI or symptoms of depression this
admission. She was continued on home fluoxetine and trazadone.
TRANSITIONAL ISSUES
======================
[] The patient complained of difficulty swallowing. An EGD has
already been ordered for her as outpatient.
[] The patient's TSH was found to be very high. Please re-check
TSH in ___ weeks to assess for effect of thyroid replacement
hormone.
[] The patient was found to be hypotensive this admission, so
her home lisinopril was discontinued. Please re-check BP and
assess for need for anti-hypertensive regimen.
[] The patient was noted to have a microcytic anemia with Hbg
slightly decreased from prior baseline. Review of prior data
indicates that she has always had a low MCV. Iron studies were
not suggestive of iron deficiency. Please recheck CBC and
consider testing for thalassemia if indicated.
[] Also, would recommend that the patient have a colonoscopy for
age appropriate cancer screening.
#CODE STATUS: Full code confirmed
#CONTACT: ___ ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Chest pressure, orthopnea, dyspnea on exertion
Major Surgical or Invasive Procedure:
___ AVR(21 StJ tissue)CABG x2(free LIMA-LAD,SVG-OM)
History of Present Illness:
___ year old female with severe aortic stenosis, moderate to
severe mitral regurgitation and moderate tricuspid regurgitation
here with chest pressure and shortness of breath.
Patient is normally quite active (water aerobics, etc) but since
the ___ has noted worsening dyspnea on exertion. She was
diagnosed with AS (valve area 0.5cm2), MR, and TR in ___
and was scheduled to undergo cardiac cath on ___ prior to AVR
with possible MVR and CABG on ___.
Over the past week, the patient has noted worse DOE - unable to
attend water aerobics, short of breath walking from one end of
the house to the other. This exacerbation seemed insidious. On
___, she felt acutely short of breath after walking from her
car. This was accompanied by chest pressure. The pressure
improved with rest but persisted. Lying flat seemed to make her
symptoms worse so she slept sitting in a chair. At that time,
she did not have any nausea, vomiting, dizziness, chest pain,
jaw pain, arm pain, back pain, syncope, PND, peripheral edema,
claudication.
Of note, she has gained about 5lbs in the past week, and has had
a decreased appetite along with some abdominal distention. She
has a chronic non-productive cough for the past year that seems
worse when lying flat. She has noted that she has had to use two
pillows to sleep instead of one at night for the past month.
Denies fevers or chills.
In the ED, initial vitals were 98.4 133/82 86 18 100%RA.
ECG showed sinus arrhythmia at 77 with LV strain pattern. Labs
notable for trop 0.01, sodium of 128, bicarb 19 w/o gap, creat
0.4, BNP 6579, D-dimer 774. CXR showed moderate pulmonary edema,
?atypical infxn. CTA Chest shows diffuse opacifications c/w
edema vs infection. Patient received ASA and 2.5mg morphine x 1
with resolution of her pain and great improvement to her SOB.
Currently, patient has mild shortness of breath and her chest
pressure is 0-1/10. She is very mildly nauseated. There is no
light-headedness, dizziness, palpitation, lower extremity edema.
She denies any hx of TIA/stroke, blood clots, myalgias, joint
pains, hemoptysis, black stools, bloody stools (recent
hemorrhoid that resolved w/suppositories), constipation,
diarrhea, dysuria, hematuria, oliguria.
Past Medical History:
Aortic Stenosis
Coronary Artery Disease
acute systolic congestive heart failure
PMH:
Hyperlipidemia
Hypothyroidism
Hyponatremia
GERD
Depression
Intersitial fibrosis (per patient this is also inaccurate,
though
fibrosis was noted on OSH CT scan in ___, followed by ___ of Pulmonology)
Osteopenia
Social History:
___
Family History:
Mother with ___ Heart disease and mitral valve disease,
died of CHF at ___. Father died at ___. No family hx of SCD or
CAD.
Physical Exam:
Admission exam:
99.1 99/53 88 18 98 2L 73.3kg
GENERAL: Pleasant WDWN woman in NAD. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric.
NECK: Supple with JVP of 10 cm.
CARDIAC: RRR. Harsh ___ systolic murmur heard throughout
precordium but best at R/LUSB w/radiation to carotids. The
tricuspid and mitral positions show a more holosystolic murmur
that does not appear to have respirophasic variation. No S3,4.
LUNGS: Two distinct patterns of rales. Early inspiratory rales
at both bases. Mid-late inspiratory rales heard across most of
both lung fields. Speaking in full sentences without distress or
accessory muscle use. No acral cyanosis.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e. 1+ ___, 2+ radial
Pertinent Results:
___ Intra-op TEE
Conclusions
Pre-CPB:
The left atrium is mildly dilated. Mild spontaneous echo
contrast is present in the left atrial appendage. The left
atrial appendage emptying velocity is depressed (<0.2m/s). No
atrial septal defect is seen by 2D or color Doppler.
There is mild symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. Overall left ventricular
systolic function is moderately depressed (LVEF= 35 %). Right
ventricular chamber size and free wall motion are normal.
The ascending aorta is mildly dilated. There are simple atheroma
in the descending thoracic aorta. No thoracic aortic dissection
is seen. The aortic valve is bicuspid. The aortic valve leaflets
are severely thickened/deformed. There is critical aortic valve
stenosis (valve area <0.8cm2). Trace aortic regurgitation is
seen.
The mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen.
___ was notified in person of the results at time of
study.
.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Alendronate Sodium 70 mg PO Frequency is Unknown
2. Lovastatin *NF* 10 mg Oral daily
3. Multivitamins 1 TAB PO DAILY
4. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
5. Aspirin 81 mg PO DAILY
6. Fluoxetine 20 mg PO BID
7. Levothyroxine Sodium 50 mcg PO DAILY
8. Vitamin D 400 UNIT PO DAILY
9. Calcium Carbonate 500 mg PO Frequency is Unknown
Discharge Medications:
1. Aspirin EC 81 mg PO DAILY
RX *aspirin [Adult Low Dose Aspirin] 81 mg 1 tablet(s) by mouth
daily Disp #*60 Tablet Refills:*1
2. Levothyroxine Sodium 75 mcg PO DAILY
RX *levothyroxine 75 mcg 1 tablet(s) by mouth daily Disp #*60
Tablet Refills:*1
3. Multivitamins 1 TAB PO DAILY
4. Carvedilol 3.125 mg PO BID
RX *carvedilol 3.125 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*1
5. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*1
6. Ranitidine 150 mg PO BID
RX *ranitidine HCl 150 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*1
7. TraMADOL (Ultram) 50 mg PO Q4H:PRN pain
RX *tramadol 50 mg 1 tablet(s) by mouth q4h prn Disp #*45 Tablet
Refills:*0
___ MD to order daily dose PO DAILY
RX *warfarin [Coumadin] 2.5 mg Daily per MD ___ by mouth
daily Disp #*150 Tablet Refills:*1
9. Alendronate Sodium 70 mg PO RESUME PREOP DOSING
10. Calcium Carbonate 500 mg PO RESUME PREOP DOSING
11. Vitamin D 400 UNIT PO DAILY
12. Lovastatin *NF* 10 mg ORAL DAILY
13. Warfarin 5 mg PO ONCE Duration: 1 Doses
RX *warfarin [Coumadin] 5 mg 1 tablet(s) by mouth once Disp #*1
Tablet Refills:*0
14. Isosorbide Mononitrate (Extended Release) 15 mg PO DAILY
RX *isosorbide mononitrate [Imdur] 30 mg 0.5 (One half)
tablet(s) by mouth daily Disp #*60 Tablet Refills:*1
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Aortic Stenosis
Coronary Artery Disease
acute systolic congestive heart failure
PMH:
Hyperlipidemia
Hypothyroidism
Hyponatremia
GERD
Depression
Intersitial fibrosis (per patient this is also inaccurate,
though
fibrosis was noted on OSH CT scan in ___, followed by ___ of Pulmonology)
Osteopenia
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Edema
Followup Instructions:
___
Radiology Report
HISTORY: ___ female with severe aortic stenosis and coronary artery
disease, now with concern for pulmonary fibrosis versus volume overload;
recent diuresis performed.
STUDY: AP portable upright chest radiograph.
COMPARISON: Chest radiograph and chest CTA from ___.
FINDINGS: The heart size is within normal limits. The mediastinal and hilar
contours are normal. Again are seen diffuse areas of ground-glass opacities
are similar to slightly improved in extent from prior exam. There is no large
pleural effusion or pneumothorax. No pulmonary consolidation is present.
IMPRESSION: Diffuse ground-glass opacities with minimal improvement after
diuresis most compatible with either an atypical infection or inflammatory
process.
Radiology Report
AP CHEST, 5:39 P.M., ___
HISTORY: After CABG and AVR. Assess lines and tubes and complications.
IMPRESSION: AP chest compared to ___:
Mediastinum has a normal post-operative appearance, particularly given supine
positioning. There is no evidence of mediastinal bleeding or other fluid
accumulation. Swan-Ganz catheter probably ends in the left descending
pulmonary artery. ET tube is in standard placement. An upper enteric tube
would need to be advanced 6 cm to move all the side ports into the stomach.
Midline drains in place. Pleural effusion minimal if any. No pneumothorax.
Pre-operative edema has cleared from the lower lungs, but there is still
extensive peripheral opacification in both upper lobes, raising possibility of
findings not related to cardiac decompensation, such as chronic eosinophilic
pneumonia, vasculitis, or even infection.
Findings were discussed by telephone with Dr. ___ at 8:55 a.m. on
___.
Radiology Report
HISTORY: ___ female with removal of chest tube, evaluate for
pneumothorax.
COMPARISON: ___.
FINDINGS: Portable upright frontal chest radiograph demonstrates interval
removal of a left chest tube. Airspace opacity is similar in distribution
bilaterally likely reflecting edema accentuated by low lung volumes. A right
pleural effusion is increased. The postoperative cardiac silhouette and
mediastinal contours are unchanged. Median sternotomy wires are unchanged.
There has been interval removal of an endotracheal tube, NG tube, epicardial
pacing wires, right IJ sheath, and Swan-Ganz catheter. There may be a trace
left pneumothorax without evidence of tension. The stomach is distended with
air.
IMPRESSION: Increasing right pleural effusion and pulmonary edema,
exaggerated by low lung volumes status post extubation.
Radiology Report
CLINICAL HISTORY: Pulmonary edema, on therapy, evaluate for improvement.
CHEST: The current film is considerably better penetrated than the prior film
of ___. The degree of failure is probably the same. Some areas show
more opacification, others less. The right effusion, however, is probably
less.
IMPRESSION: Little change in the degree of failure.
Radiology Report
CLINICAL HISTORY: Central venous line placed, check position.
The right subclavian line has gone into the internal jugular vein and its tip
cannot be seen.
Focal opacities are again noted within both the right and left lobes and a
right effusion is likely present. These could represent a patchy
bronchopneumonia rather than resolving failure.
IMPRESSION: Central line in right neck.
Radiology Report
CLINICAL HISTORY: Central line repositioned. Check current status.
The tip of the right central line now lies in the mid-to-lower SVC in a good
position. The patchy focal opacities remain unchanged in both lungs.
IMPRESSION: Tip of central line in SVC.
Radiology Report
HISTORY: Post-operative changes.
FINDINGS: In comparison with the study of ___, the patient has taken a much
better inspiration. Blunting of the costophrenic angles persists as well as
an area of patchy opacification in the right mid zone laterally. There has
been substantial improvement in the other areas of scattered pulmonary
opacification.
Radiology Report
___
Department of Radiology
Standard Report Carotid US
Study: Carotid Series Complete
Reason: ___ year old woman with severe AS planned for surgical repair.
Findings: Duplex evaluation was performed of bilateral carotid arteries. On
the right there is moderate calcified plaque in the ICA. On the left there is
mild heterogeneous plaque seen in the ICA.
On the right systolic/end diastolic velocities of the ICA proximal, mid and
distal respectively are 135/38, 108/35, 116/53 cm/sec. CCA peak systolic
velocity is 83/28 cm/sec. ECA peak systolic velocity is 78 cm/sec. The ICA/CCA
ratio is 1.6. These findings are consistent with 40-59% stenosis.
On the left systolic/end diastolic velocities of the ICA proximal, mid and
distal respectively are 113/42, 91/27, 106/25 cm/sec. CCA peak systolic
velocity is 74/20 cm/sec. ECA peak systolic velocity is 176 cm/sec. The
ICA/CCA ratio is 1.5 . These findings are consistent with 40-59% stenosis.
Right antegrade vertebral artery flow.
Left antegrade vertebral artery flow.
Impression: Right ICA 40-59% stenosis.
Left ICA 40-59% stenosis.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: SOB/HEART RACING
Diagnosed with CHEST PAIN NOS, SHORTNESS OF BREATH
temperature: 98.4
heartrate: 86.0
resprate: 18.0
o2sat: 100.0
sbp: 133.0
dbp: 82.0
level of pain: 7
level of acuity: 2.0 | MEDICINE COURSE:
___ with severe AS scheduled for repair here with increased
dyspnea on exertion and chest pressure. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Chantix / Ambien
Attending: ___.
Chief Complaint:
Wound vac failure
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year-old male well-known to the colorectal
service who presents with a malfunctioning wound VAC. The
patient
has a complex surgical history and currently has a controlled
colocutaneous fistula. The fistula emerges through and large
abdominal wound that has been recently skin grafted. The patient
was recently discharged with an ostomy appliance over the
fistula
and a wound VAC over the remaining wound. This patient has been
in rehab and the VAC was changed last week in wound care clinic.
He presents today with his VAC malfunctioning and leakage of
stool from around the VAC. He otherwise has been doing well.
Past Medical History:
PMH:
Complicated diverticulitis
Depression
Anxiety
Alcoholism
Hx of LUE DVT and PE
HTN
COPD
CAD
PAD/PVD - s/p arterial stenting in the left leg, indwelling
Foley with leg bag, (placed by Dr. ___ for a hole in his
bladder
H/o MRSA
H/o VRE UTI
PSH:
___ Endoscopic clipping across fistula, replaced stent
___ STSG from R thigh
___ Metal stent placed
___ - Exploratory laparotomy, partial colectomy with
hand-sewn
colocolonic anastomosis. Ventral hernia repair with an inlay
bridge of Phasix ST and skin flap advancement flaps
___ - Cystoscopy and bilateral stent placement by Dr.
___.
Laparotomy, lysis of adhesions, takedown ileostomy with
resection of ileostomy, takedown of enterocutaneous fistula with
repair of colocolostomy, and flexible sigmoidoscopy. Ventral and
parastomal hernia repair with Ventralight mesh and
panniculectomy
by Dr. ___.
___ - Gtube placement, diverting loop ileostomy,
appendectomy
___ - Take-back exlap, partial colectomy and secondary
colostomy, exlap/LOA, Takedown of colovesical fistula, Repair of
bladder fistula, Sigmoid colon resection, End to end anastomosis
of the descending colon to rectum, Take down of prolapsed end
transverse colostomy with resection of end ostomy. Side to side
antiperistaltic anastomosis between the transverse and
descending
colon.
___ - Reversal/takedown of ___ c/b septic shock and
anastomotic leak
___ - ___ procedure for obstruction, complicated by
cardiac arrest intraoperatively -> emergent colostomy
___ - CABG x3
Social History:
___
Family History:
Father passed away from MI, at age ___. Mother passed away
from unknown reasons, at a young age
Physical Exam:
Vitals:AVSS
Gen: AAOx3 NAD
CV: NRRR
Chest: Clear without deformity
Abd: Soft, at baseline level of distension. Notable for appx
10x8 cm abdominal wound with appropriately healing skin graft on
left lateral portion of wound. CC fistula itself is located at
right mid-lateral portion of wound, no active flow of stool.
There is some mild to moderate tissue breakdown and friability
immediately surrounding the fistula site with minor bleeding.
There is no guarding.
Extrem: Without deformity or edema
Pertinent Results:
___ 06:25AM BLOOD WBC-6.2 RBC-3.14* Hgb-9.2* Hct-29.0*
MCV-92 MCH-29.3 MCHC-31.7* RDW-16.4* RDWSD-55.8* Plt ___
___ 11:15AM BLOOD WBC-7.7 RBC-3.20* Hgb-9.5* Hct-29.6*
MCV-93 MCH-29.7 MCHC-32.1 RDW-16.8* RDWSD-56.8* Plt ___
___ 11:15AM BLOOD Neuts-38.1 ___ Monos-12.3
Eos-10.4* Baso-0.9 Im ___ AbsNeut-2.94# AbsLymp-2.92
AbsMono-0.95* AbsEos-0.80* AbsBaso-0.07
___ 06:25AM BLOOD Plt ___
___ 11:15AM BLOOD Plt ___
___ 11:15AM BLOOD ___ PTT-29.0 ___
___ 07:53AM BLOOD Glucose-84 UreaN-10 Creat-0.9 Na-139
K-3.5 Cl-108 HCO3-19* AnGap-16
___ 06:25AM BLOOD Glucose-95 UreaN-9 Creat-0.9 Na-138 K-3.6
Cl-102 HCO3-25 AnGap-15
___ 11:15AM BLOOD Glucose-107* UreaN-11 Creat-1.0 Na-135
K-4.9 Cl-101 HCO3-24 AnGap-15
___ 07:53AM BLOOD Calcium-8.9 Phos-3.8 Mg-1.8
___ 06:25AM BLOOD Calcium-8.9 Phos-4.3 Mg-1.7
___ 11:26AM BLOOD Lactate-1.4
Medications on Admission:
1. Acetaminophen 1000 mg PO Q8H:PRN pain
2. Escitalopram Oxalate 20 mg PO DAILY
3. Fluticasone Propionate NASAL 1 SPRY NU DAILY
4. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
5. LOPERamide 2 mg PO Q6H
6. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN Pain
7. LORazepam 0.5 mg PO Q4H:PRN anxiety/sleep
8. Octreotide Acetate 100 mcg SC Q8H
9. Pantoprazole 40 mg PO Q12H
10. Tiotropium Bromide 1 CAP IH DAILY
11. Levofloxacin 750 mg PO Q24H
12. Vancomycin Oral Liquid ___ mg PO/NG Q6H
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
do not drink alcohol while taking this medication, do not take
more than 3000mg in 24 hours
RX *acetaminophen 325 mg 1 tablet(s) by mouth every six (6)
hours Disp #*55 Tablet Refills:*0
2. Cholestyramine 4 gm PO TID
RX *cholestyramine (with sugar) 4 gram 1 powder(s) by mouth
three times a day Disp #*90 Packet Refills:*0
3. Escitalopram Oxalate 20 mg PO DAILY
RX *escitalopram oxalate 20 mg 1 tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*0
4. HYDROmorphone (Dilaudid) ___ mg PO Q6H:PRN pain
do not drink alcohol or drive a car while taking, please try to
take less and less pain medication
RX *hydromorphone [Dilaudid] 2 mg ___ tablet(s) by mouth every
six (6) hours Disp #*80 Tablet Refills:*0
5. LOPERamide 2 mg PO Q6H
RX *loperamide 2 mg 1 tablet by mouth every six (6) hours Disp
#*120 Tablet Refills:*0
6. LORazepam 1 mg PO Q8H:PRN anxiety/sleep
RX *lorazepam 1 mg 1 tablet by mouth every eight (8) hours Disp
#*28 Tablet Refills:*0
7. Psyllium Powder 1 PKT PO BID
RX *psyllium husk (aspartame) [Metamucil Fiber Singles] 3.4 gram
1 powder(s) by mouth twice a day Disp #*60 Packet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Wound vac failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ year old man with multiple previous abdominal surgeries c/b
ECF, admit for management of high ECF output, metal stent placement by GI
across the fistula now with increasing output // assess stent position
TECHNIQUE: Supine abdominal radiograph was obtained.
FINDINGS:
There are no abnormally dilated loops of large or small bowel. Colonic stent
is no longer visualized. Moderate stool burden is mainly in the right colon.
Supine assessment limits detection for free air; there is no gross
pneumoperitoneum.
Osseous structures are unremarkable.
Median sternotomy wires are noted. Clips are noted in the inferior pelvis.
IMPRESSION:
Colonic stent is no longer visualized. No bowel dilation.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Wound eval
Diagnosed with Unsp complication of internal prosth dev/grft, init, Exposure to other specified factors, initial encounter
temperature: 98.0
heartrate: 79.0
resprate: 18.0
o2sat: 96.0
sbp: 118.0
dbp: 92.0
level of pain: 7
level of acuity: 2.0 | Mr. ___ was admitted to ___ on ___ following failure of
his wound vac appliance at rehab facility. He was medically well
and stable throughout the course of his admission. He was
maintained on a regular diet and his home medication regimen
without changes except for discontinuation of octreotide and his
antibiotic regimen. Due to significant friability surrounding
the skin immediately adjacent to the fistula itself, attempt to
apply a pouch or adhesive dressing was aborted. The wound was
istead dressed from the time of admission with a damp to dry
dressing. Wound/ostomy care consult was involved and continued
dressing with nonstick damp to dry dressing which was changed
once daily.
At the time of discharge, Mr. ___ was tolerating regular diet,
on his home medications, ambulating, completing self care and
toileting himself normally. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Iodine-Iodine Containing / amoxicillin
Attending: ___.
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is an ___ year old woman with history of COPD not on
O2, HTN, HLD, who presents with cough, SOB, subjective fever,
chills, body aches.
Ms. ___ has a history of COPD without frequent
exacerbations. She was admitted ___ with hemoptysis with
evidence of bronchial artery bleeding that was not able to be
embolized that self resolved. Since that time she has quit
smoking cigarettes.
Beginning ___ she has felt subjective fevers, diarrhea,
myalgias, decreased appetite, and cough with increased green
sputum production. She thought symptoms were improving
throughout the week, however last night she was unable to lay
flat and was up all night coughing. This morning she checked her
ambulatory O2 sat which was 87%. This was very concerning to her
which prompted evaluation at ___ urgent ___. There her O2
sat was 88%. CXR there normal other than likely atelectasis.
Given hypoxemia patient was transferred to ___ for further
evaluation.
In the ED, initial vitals were:
97.9 85 129/79 14 96% Nasal Cannula
Exam notable for scattered wheezing, no resp distress, no lower
extremity edema. Peak flow 100, repeat 120
Labs notable for WBC 13.7 with 91.6% PMN, bicarb 16 Cr 0.9,
baseline 0.5-0.6, lactate 1.1, UA with trace blood, bacteria,
large leuks, neg nitrites
Imaging notable for CXR
Streaky opacities in the lung bases may reflect areas of
atelectasis, though early infection cannot be completely
excluded in the correct clinical setting. No focal
consolidation.
Patient was given
Azithromycin 500 mg
PO PredniSONE 60 mg
IH Albuterol 0.083% Neb Soln 1 NEB
IH Ipratropium Bromide Neb 1 NEB
Decision was made to admit for COPD exacerbation
Vitals on transfer
89 12 97% Nasal Cannula
On the floor, patient reports feeling better after breathing
treatment. Last loose stool on ___. No nausea or vomiting.
She notes several weeks ago she had bilateral lower extremity
swelling so she took her husband's HCTZ with subsequent 7lb
weight loss and resolution of lower extremity swelling. She
discussed with her PCP who thought this was related to her
recent NSAID use but had planned for TTE which is ordered for
___. She has not had previous episodes of orthopnea, PND,
lower extremity edema, dyspnea on exertion. She has also not had
chest pain, palpitations.
Past Medical History:
COPD
HTN
hypercholesterolemia
bladder CA s/p surgical removal ___
s/p breast lump/cyst removal
rheumatic fever
Social History:
___
FAMILY HISTORY:
Breast cancer in sister, cousins. T2DM in brother, father. No
FHx of bleeding.
Family History:
Breast cancer in sister, cousins. T2DM in brother, father. No
FHx of bleeding.
Physical Exam:
Admission Physical Exam:
====================
VS: 98.6 PO 146 / 77 R Sitting 90 20 95 2L NC
Gen: very pleasant well appearing older woman speaking in full
sentences in NAD
HEENT: PERRL, EOMI, +erythema in posterior pharynx, no exudate
CV: RRR, S1, S2 with no m/r/g
Pulm: decreased breath sounds, no crackles, wheezes, rhonchi
Abd: soft, non distended, non tender to palpation, +BS
GU: no CVA tenderness
Ext: warm, well perfused, no edema
Skin: no rashes
Neuro: AxOx3, CNII-XII intact, moving all 4 extremities without
deficit
Discharge Physical Exam:
====================
VS: 97.9 132 / 73 84 20 92-95% RA; 85-93% ambulatory sat, on
room air
Gen: well appearing, A&Ox3, sitting up in chair in no acute
distress; talking in full sentences;
HEENT: MMM
Neck: No JVP elevation sitting at 45 degree angle in bed
Resp: Good air movement; lungs are clear without wheezes;
diminished at base; talking in full sentences; able to carry on
conversation while ambulating
Cardiac: RRR, S1, S2, no murmurs
Abd: soft, non-tender
Ext: no peripheral edema
Gait: steady without walker
Pertinent Results:
Admission Labs:
===============
___ 04:55PM BLOOD WBC-13.7* RBC-4.31 Hgb-11.8 Hct-36.3
MCV-84 MCH-27.4 MCHC-32.5 RDW-13.4 RDWSD-41.5 Plt ___
___ 04:55PM BLOOD Neuts-91.6* Lymphs-4.7* Monos-2.9*
Eos-0.2* Baso-0.2 Im ___ AbsNeut-12.53*# AbsLymp-0.65*
AbsMono-0.40 AbsEos-0.03* AbsBaso-0.03
___ 04:39PM BLOOD Glucose-122* UreaN-22* Creat-0.9 Na-134
K-4.7 Cl-94* HCO3-16* AnGap-29*
___ 07:32AM BLOOD Calcium-8.8 Phos-3.7 Mg-2.4
___ 04:39PM BLOOD proBNP-215
___ 04:48PM BLOOD Lactate-1.1
Discharge Labs:
===============
___ 07:32AM BLOOD WBC-10.6* RBC-4.04 Hgb-11.0* Hct-34.3
MCV-85 MCH-27.2 MCHC-32.1 RDW-13.4 RDWSD-42.0 Plt ___
___ 07:32AM BLOOD Glucose-133* UreaN-22* Creat-0.7 Na-134
K-4.8 Cl-92* HCO3-23 AnGap-24*
Imaging:
===============
___ CXR
Streaky opacities in the lung bases may reflect areas of
atelectasis, though
early infection cannot be completely excluded in the correct
clinical setting.
No focal consolidation.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: History: ___ with shortness of breath, COPD, sputum production
// pneumonia?
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph ___, CT chest ___
FINDINGS:
Mild enlargement of the cardiac silhouette is unchanged. The aorta remains
mildly tortuous with dilatation of the ascending aorta better delineated on
the recent CT. Hilar contours are within normal limits. The pulmonary
vasculature is not engorged. Lungs are hyperinflated. Streaky opacities are
noted in both lung bases, which may reflect atelectasis. No focal
consolidation, pleural effusion or pneumothorax is present. There are no
acute osseous abnormalities.
IMPRESSION:
Streaky opacities in the lung bases may reflect areas of atelectasis, though
early infection cannot be completely excluded in the correct clinical setting.
No focal consolidation.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Dyspnea, Fever, Productive cough
Diagnosed with Chronic obstructive pulmonary disease w (acute) exacerbation
temperature: 97.9
heartrate: 85.0
resprate: 14.0
o2sat: 96.0
sbp: 129.0
dbp: 79.0
level of pain: 0
level of acuity: 2.0 | ___ with hx of COPD, 60-120 pack year smoking history (recently
quit), presents with dyspnea for 3 days and hypoxia at home to
87% on room air. Baseline is >95% on room air at rest.
# COPD exacerbation: CXR showed mild atelectasis. No evidence of
hypervolemia on exam. Most likely COPD exacerbation, and treated
with nebulizer, steroid, azithromycin with improvement. On
hospital day 2 she felt improved, and resting O2 saturation 95%
on room air. Able to ambulate around the hallway without
significant dyspnea. Ambulatory O2 between 85-93% on room air.
She had good air movement on lung exam. She was discharged with
prednisone/azithromycin for total 5 day course. She was
prescribed albuterol nebulizer equipment and treatments for
future exacerbations, but the equipment was unable to be
obtained prior to discharge. PCP was contacted to assist with
obtaining this. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Left leg pain
Major Surgical or Invasive Procedure:
ORIF left tib/fib fracture
History of Present Illness:
___ year old woman with PMH of Left septic hip s/p resection
arthroplasty in ___ complicated by DVT presents s/p mechanical
fall at home with marked left ankle pain and deformity. The
patient was cleaning her apartment this evening when she slipped
and fell, twisting her left ankle underneath her. She felt
immediate pain and deformity. She was transported to ___ in
stable condition by EMS
Past Medical History:
-Hepatitis C
-HTN
-HLD
-Frequent Falls
-Past C-section
Social History:
___
Family History:
nc
Physical Exam:
T-96.6 HR-107 BP-112/63 RR-18 SaO2-100% RA
A&O x 3
Calm and comfortable
BUE skin clean and intact
No tenderness, deformity, erythema, edema, induration or
ecchymosis
Arms and forearms are soft
No pain with passive motion
R M U ___
EPL FPL EIP EDC FDP FDI fire
2+ radial pulses
LLE skin clean and intact
Marked tendernes and deformity about left ankle. No erythema,
edema, induration or ecchymosis
Thighs and legs are soft
No pain with passive motion
Saph Sural DPN SPN MPN LPN ___ FHL ___ TA PP Fire
1+ ___ and DP pulses
IMAGING:
Ankle 3 views: Fracture of the distal third of the tibia and
fibula ~3 cm proximal to the ankle joint.
Pertinent Results:
___ 02:06PM GLUCOSE-120* UREA N-12 CREAT-0.7 SODIUM-140
POTASSIUM-4.8 CHLORIDE-105 TOTAL CO2-27 ANION GAP-13
___:06PM MAGNESIUM-1.8
___ 02:06PM WBC-8.8 RBC-3.42* HGB-11.3* HCT-36.3 MCV-106*
MCH-33.1* MCHC-31.3 RDW-12.3
___ 02:06PM PLT COUNT-308
___ 01:00AM GLUCOSE-118* UREA N-13 CREAT-0.7 SODIUM-140
POTASSIUM-3.8 CHLORIDE-102 TOTAL CO2-22 ANION GAP-20
___ 01:00AM estGFR-Using this
___ 01:00AM WBC-12.8* RBC-3.83*# HGB-13.1# HCT-40.4#
MCV-105*# MCH-34.2* MCHC-32.4 RDW-12.4
___ 01:00AM NEUTS-73.4* ___ MONOS-3.7 EOS-1.0
BASOS-0.7
___ 01:00AM PLT COUNT-364
___ 01:00AM ___ PTT-26.0 ___
Medications on Admission:
Cyclobenzaprine 5mg q8 prn
Zolpidem 5 mg qhs prn
Discharge Medications:
1. oxycodone 5 mg Tablet Sig: ___ Tablets PO Q4H (every 4 hours)
as needed for Pain: Do not drink alcohol or drive while on this
medication.
Disp:*100 Tablet(s)* Refills:*0*
2. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
4. trazodone 50 mg Tablet Sig: One (1) Tablet PO QHS (once a day
(at bedtime)) as needed for Insomnia.
5. enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) Syringe
Subcutaneous QHS (once a day (at bedtime)) for 4 weeks.
Disp:*28 Syringe* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Left distal tib/fib fracture s/p ORIF
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
INDICATION: ___ female with fall and pain in the distal tibia/fibula.
Evaluate for fracture.
FINDINGS: A comminuted fracture of the left distal tibia and fibula are noted
with posterior displacement of the distal fracture fragment with respect to
the proximal fragment. No soft tissue calcifications or radiopaque foreign
bodies are identified.
Findings discussed with Dr. ___ at 2:00 a.m. on ___ via telephone.
Radiology Report
INDICATION: ___ female with fall and pain in the distal tibia/fibula.
Evaluate for fracture.
Single view of the chest obtained. Comparison made to images from ___.
Bilateral low lung volumes are noted with crowding of bronchovascular
markings. Cardiac silhouette is extenuated by low lung volumes.
Radiology Report
LEFT FIB AND TIB, TWO VIEWS
REASON FOR EXAM: Reduction of fracture.
Comparison is made with prior study performed two hours earlier.
There is new cast in the right ankle. Comminuted fractures of the left distal
tibia and fibula are less displaced than before. There is no evidence of
dislocation.
Radiology Report
LEFT FIB AND TIB
REASON FOR EXAM: ORIF.
Seven fluoroscopic views of the left ankle were submitted show sequential
steps of ORIF of the distal fibula and tibia for comminuted fractures of the
distal fibula and tibia. For more detailed description, please refer to the
OR note.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: LEFT TIB/FIB INJURY
Diagnosed with FX SHAFT FIB W TIB-CLOS, UNSPECIFIED FALL, HYPERTENSION NOS, JOINT REPLACEMENT-HIP
temperature: 96.6
heartrate: 107.0
resprate: 18.0
o2sat: 100.0
sbp: 112.0
dbp: 63.0
level of pain: 10
level of acuity: 2.0 | The patient was admitted to the Orthopaedic Trauma Service for
repair of a left tib/fib fracture. The patient was taken to the
OR and underwent an uncomplicated open reduction and internal
fixation. The patient tolerated the procedure without
complications and was transferred to the PACU in stable
condition. Please see operative report for details. Post
operatively pain was controlled with a PCA with a transition to
PO pain meds once tolerating POs. The patient tolerated diet
advancement without difficulty and made steady progress with ___.
Weight bearing status:
Touch-down weight bearing left lower extremity.
The patient received ___ antibiotics as well as
Lovenox for DVT prophylaxis. The incision was clean, dry, and
intact without evidence of erythema or drainage; and the
extremity was NVI distally throughout. The patient was
discharged in stable condition with written instructions
concerning precautionary instructions and the appropriate
follow-up care. The patient will be continued on chemical DVT
prophylaxis for 4 weeks post-operatively. All questions were
answered prior to discharge and the patient expressed readiness
for discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Left foot drop
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year-old R handed who presents with worsening L buttock and L
lower
leg pain over several months and 2 days of left foot drop.
Pt reports that has been dealing with left buttock pain and left
left lower leg pain for years. She also has a history of b/l
knee severe OA that is left worse than right that she has been
dealing with. She notes that a left TKR has been delayed due to
recent MI and requiring antiplatelets for stents. She reports
that she has never gotten spine imaging and she has never
brought up the following problems with her PCP.
Over the last several months, she has gradual worsening of her
left buttock pain, aching pain from her left knee down her
anterior leg into her foot, as well as increased left knee pain
when standing. She has tried several doses of ibuprofen and
Tylenol without much relief. Instead, she has just become less
active and has been sitting more due to the pain. She is able to
walk but has increased pain in that left leg when doing so that
makes her stop. No history of trauma or recent strenuous
activity. Denies electric pain radiating from buttock down the
back of her leg.
2 days ago, she was getting into her car and trying to use her
left leg on the pedals when she felt that something was not
right because she could not lift her foot well. This has become
a noticeable problem with walking but she feels that the problem
is stable.
At ___, she had hypokalemia ordered for 20meq PO and
20meq in fluids. She takes 40meq PO daily at home. She was
transferred to ___ for MRI as they did not have overnight MRI
capabilities there.
Past Medical History:
- CAD s/p MI and 2 cardiac stents ___
- Kidney stones
- OA in both knees
Social History:
___
Family History:
No family history of stroke or neurologic disease.
Physical Exam:
==============
ON ADMISSION
==============
Vitals: 98.3F, HR 96, BP 169/89 RR 16, 100% on RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, ++ bowel sounds. No masses palpated.
Extremities: very mild ___ edema bilaterally.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name ___ backward without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic errors.
Pt was able to name both high and low frequency objects. Speech
was not dysarthric. Able to follow both midline and appendicular
commands. There was no evidence of apraxia or neglect.
-Cranial Nerves:
II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI several beats
end gaze nystagmus bilaterally. VFF to confrontation.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 1 5 4- 3
R 5 ___ ___ 5 5 5 5 5 5 5
-Sensory: Decreased light touch and pinprick over superior and
slightly mediated left ankle/foot. Does not include toes. R toe
14 seconds, L toe 10 seconds. Big toe joint proprioception
intact, left toe is slightly decreased to smaller movements. No
extinction to DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 1 1
R 2 2 2 2 1
Plantar response was mute on the left and up on the right vs
withdrawal. NO ankle clonus. No pectoral jerks or crossed
adductor.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF. No ataxia on toe to finger.
-Gait: deferred.
==============
ON DISCHARGE
==============
General: Awake, cooperative, NAD.
Neurologic: Alert, oriented x 3. Able to relate history
without difficulty.Language is fluent with intact repetition and
-Cranial Nerves:
II, III, IV, VI: PERRL. EOMI
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to conversation.
IX, X: Palate elevates symmetrically.
XI: Full strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 1 5 3 3
R 5 ___ ___ 5 5 5 5 5 5 5
-Sensory: Decreased pinprick over medial left foot through
ankle. Intact to light touch throughout. Proprioception intact.
Pertinent Results:
___ MRI L SPINE W/O CONTRAST
IMPRESSION:
1. Multilevel degenerative changes of the lumbar spine, most
advanced at
L4-L5, where there is severe spinal canal and moderate left
neural foraminal stenosis.
2. Partially visualized aneurysmal dilatation of the infrarenal
abdominal
aorta, better evaluated on the CTA performed ___.
Medications on Admission:
Plavix 75mg daily
Atorvastatin 80mg daily
ASA 81mg daily
Atenolol 50mg daily
Losartan 100mg daily
Protonix 40mg daily
CHlorthalidone 25mg daily
KCl ER 40meq daily
Vitamin D3 1000mg daily
Discharge Medications:
1. Atenolol 50 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
3. Chlorthalidone 25 mg PO DAILY
4. Losartan Potassium 100 mg PO DAILY
5. Pantoprazole 40 mg PO Q24H
6. Acetaminophen 650 mg PO Q6H:PRN pain
Do not take concurrently with Percocet, please take one or the
other, or alternate every 6 hours
7. OxyCODONE--Acetaminophen (5mg-325mg) 1 TAB PO Q4H:PRN pain
Do not take concurrently with Tylenol as it contains
acetaminophen. Please take one or the other.
RX *oxycodone-acetaminophen 5 mg-325 mg 1 tablet(s) by mouth
every four (4) hours Disp #*20 Tablet Refills:*0
8. Docusate Sodium 100 mg PO BID constipation
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*30 Capsule Refills:*0
Discharge Disposition:
Home with Service
Discharge Diagnosis:
L4-L5 spinal stenosis & left neural foraminal stenosis.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: MR ___ SPINE W/O CONTRAST
INDICATION: ___ with chronic left buttock pain with 2 days of L foot drop //
eval for acute process
TECHNIQUE: Sagittal imaging was performed with T2, T1, and STIR technique,
coronal T2, followed by axial T2 imaging.
COMPARISON: CT urogram ___
CTA abdomen and pelvis ___
FINDINGS:
The S-shaped scoliosis of the lower thoracic and lumbar spine with a moderate
levoscoliosis of the lumbar spine, apex at L2-L3, is unchanged. The 4 mm left
lateral listhesis of L3 on L4 and 8 mm anterolisthesis of L4 on L5 are also
unchanged. The height of the vertebral bodies are maintained. Heterogeneous
signal at the endplates of L2-L3 to L5-S1 represent mixed degenerative
endplate changes. The intervertebral disc spaces of L2-L3 to L5-S1 are
moderately to severely narrowed. The intervertebral discs are diffusely
desiccated. The conus medullaris terminates at L1-L2. Small Tarlov cysts are
visualized at the S2 level. The spinal cord is normal in signal. No fluid
collections or masses are identified. The paraspinal soft tissues are normal.
At T10-T11, T11-T12, and T12-L1, there is no spinal canal or neural foraminal
stenosis.
At L1-L2, there is no spinal canal or neural foraminal stenosis.
At L2-L3, disc bulge with superimposed right neural foraminal disc protrusion
and bilateral facet arthropathy narrows the right subarticular recess and
cause mild-to-moderate right neural foraminal stenosis. There is no spinal
canal stenosis.
At L3-L4, disc bulge, ligamentum flavum thickening, and bilateral facet
arthropathy cause mild-to-moderate spinal canal and moderate bilateral neural
foraminal stenosis.
At L4-L5, uncovering of the disc secondary to anterolisthesis with a superior
disc bulge, ligamentum flavum thickening, and bilateral facet arthropathy
cause severe spinal canal stenosis, and moderate left neural foraminal
stenosis.
At L5-S1, disc bulge and bilateral facet arthropathy cause mild bilateral
neural foraminal stenosis. There is no spinal canal stenosis.
The focal aneurysmal dilatation of the infrarenal abdominal aorta measures 3.5
cm in transverse dimension on 8:13 and is partially visualized, unchanged from
___.
IMPRESSION:
1. Multilevel degenerative changes of the lumbar spine, most advanced at
L4-L5, where there is severe spinal canal and moderate left neural foraminal
stenosis.
2. Partially visualized aneurysmal dilatation of the infrarenal abdominal
aorta, better evaluated on the CTA performed ___.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: L Leg pain, Transfer
Diagnosed with Foot drop, left foot, Hypokalemia
temperature: 98.3
heartrate: 96.0
resprate: 16.0
o2sat: 100.0
sbp: 169.0
dbp: 89.0
level of pain: 4
level of acuity: 3.0 | On ___, the patient presented to the Emergency Department for
evaluation of foot drop which she had been experiencing for 2
days. She was admitted to the neurosurgery service for
monitoring and EMG was ordered. Per neurology, EMG needle study
was unable to be completed due to Plavix, but peroneal nerve
studies only could be done. The patient was discharged home
with physical therapy and outpatient OT for AFO fitting. She was
scheduled to return for operative planning. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fevers, headache, flank pain
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
___ year old lady with history of asthma, who presents from PCP's
office with fevers, dysuria, and flank pain.
Per patient, she started experiencing fevers since last ___
up to ___ F. This was associated with a headache, which she
describes as R frontal, sharp, not associated with focal
neurological changes (no visual changes, focal weakness,
numbness, tingling, dizziness), or change in her chronic neck
pain not worsening with Valsalva or cough, not waking her up
from
sleep. She looked this up from a virtual doctor, and was told
that she could have meningitis. Alarmed, she presented to a
physical doctor in ___ on ___. At that time she shares that
blood and urine tests were sent, but she was told that
everything
was okay. She did also call the nurses afterwards and was told
to
"ride it out" and that perhaps she had fever of unknown origin.
Her fever broke on ___ night, and she felt well enough to go
to work. On ___, she had episode of severe chills, felt that
her lips turned blue, and had recurrent fever at night to 101
degrees associated with night sweats. This was accompanied by
new
L flank pain as well as decreased appetite, although no nausea
or
vomiting. Today, she presented to her primary care doctor. Per
PCP call in, there was a UCx reportedly with pansensitive E coli
> 100K. She received 1 dose of ciprofloxacin at ___'s office,
and
was sent into the ED for further evaluation.
In the ED, initial vitals: 97.8 96 103/65 99% RA
Exam notable for: comfortable appearing, afebrile.
She was complaining of headache and L flank discomfort but no
nausea, vomiting, diarrhea, or SOB. She shared that she has not
had much appetite since last ___ but was able to drink
water.
Labs:
1) WBC 10.2 Hgb 11.6 Plt 299 Neutrophils 78.1
2) Na 137 K 4.1 Cl 97 CO2 22 BUN 5 Cr 0.6
3) ALT 39 AST 19 AP 84 Tbili 0.7
4) TSH 1.5
5) U/A with negative nitrite and negative ___
___ x 2 were drawn, lyme studies were sent, urine cultures sent
as well
Imaging:
- CXR: No acute cardiopulmonary abnormality
- CT A/P: Two thick walled lesions measuring 2.0 x 1.5 cm and
1.4
x 1.2 cm, with small central fluid components, compatible with
abscesses. Circumferential wall thickening of the bladder,
greater than expected for the degree of distension, likely
representing cystitis.
She was seen by urology: "L sided flank pain is now mild but
definitely tender to palpation. Abscesses too small for drainage
at the time. Recommend IV antibiotics for now and monitoring:
foley placement. Recommend medicine admission for
pyelonephritis.
GU will follow.
She received:
- Ceftriaxone 1 g x 1
- Acetaminophen 1000 mg
Upon arrival to the floor, the patient confirms history as
above.
No acute concerns, is not interested in having Foley placed.
Of note she has no known history of ___, urinary tract
abnormalities, recent instrumentation.
Past Medical History:
Acne vulgaris
Low back pain
History of asthma
Vitamin D deficiency
Social History:
___
Family History:
Father- MI, DM, Asthma
MGM- Lung cancer
MGF- Pancreatic cancer
Uncle- Liver cancer
Aunt- ___ cancer
Uncle- Lung cancer
Physical Exam:
ADMISSION EXAM
===============
VITALS: 98.9 99/64 77 18 98% RA
GENERAL: Young female lying in bed in no acute distress
EYES: EOMI
ENT: MMM
CV: Normal rate, regular rhythm, no m/r/g
RESP: CTAB, no increased work of breathing
GI: Soft, nontender, nondistended, + BS
GU: Mild L CVA tenderness, mild TTP at flank
MSK: Normal bulk and tone
SKIN: No rashes appreciated
NEURO: CN II-XII intact, strength ___ in bilateral upper and
lower extremities, no dysmetria, no pronator drift
DISCHARGE EXAM
===============
VITALS: Tcur98.6 Tmax 100.0, 106/67, 60, 18, 98% Ra
GENERAL: Well appearing woman, not ill appearing, laying in bed,
in NAD
ENT: EOMI, MMM
CV: RRR, no m/r/g
RESP: CTAB, no wheezes or crackles
GI: Soft, non distended, mild left sided abdominal tenderness
GU: No CVA tenderness on palpation
SKIN: No rashes or lesions noted
NEURO: AO x 3
Pertinent Results:
ADMISSION LABS
================
___ 09:05AM WBC-10.2* RBC-3.93 HGB-11.6 HCT-36.3 MCV-92
MCH-29.5 MCHC-32.0 RDW-12.7 RDWSD-43.4
___ 09:05AM NEUTS-78.1* LYMPHS-10.1* MONOS-10.5 EOS-0.4*
BASOS-0.5 IM ___ AbsNeut-8.00*# AbsLymp-1.03* AbsMono-1.07*
AbsEos-0.04 AbsBaso-0.05
___ 06:50PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
___ 09:05AM UREA N-5* CREAT-0.6 SODIUM-137 POTASSIUM-4.1
CHLORIDE-97 TOTAL CO2-22 ANION GAP-18*
MICROBIOLOGY
=============
Urine culture at OSH: Growing e. coli, pan sensitive
UA at ___ negative
Ucx at ___ ___ pending
___ at ___ ___ pending
IMAGING
========
CT Abd and Pelv ___:
1. Two thick-walled lesions measuring 2.0 x 1.5 cm and 1.4 x 1.2
cm with small central fluid components, which given the clinical
history of pyelonephritis, are compatible with abscesses.
2. Circumferential wall thickening of the bladder, greater than
expected for the degree of distension, likely representing
cystitis.
RENAL US ___:
Echogenic area in the upper pole of the left kidney consistent
with
pyelonephritis, no evidence of fluid collection. Please note
that CT is more sensitive for detection of abscess formation.
DISCHARGE LABS
===============
___ 06:46AM BLOOD WBC-9.3 RBC-3.98 Hgb-11.5 Hct-36.1 MCV-91
MCH-28.9 MCHC-31.9* RDW-12.5 RDWSD-41.7 Plt ___
___ 06:46AM BLOOD Plt ___
___ 06:46AM BLOOD Glucose-89 UreaN-8 Creat-0.6 Na-143 K-4.4
Cl-102 HCO3-25 AnGap-16
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Vitamin D 400 UNIT PO DAILY
2. Multivitamins W/minerals 1 TAB PO DAILY
3. Fish Oil (Omega 3) 1000 mg PO DAILY
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day
Disp #*38 Tablet Refills:*0
2. Vitamin D 400 UNIT PO DAILY
3. Fish Oil (Omega 3) 1000 mg PO DAILY
4. Multivitamins W/minerals 1 TAB PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
E. coli pyelonephritis
L renal abscesses
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT abdomen pelvis with IV contrast.
INDICATION: ___ year old woman with fevers for a week, now with left flank
pain r/o pyelonephritis// fevers for a week, now with left flank pain r/o
pyelonephritis
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technique.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Total DLP (Body) = 352 mGy-cm.
COMPARISON: None.
FINDINGS:
LOWER CHEST: Visualized lung fields are within normal limits. There is no
evidence of pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: Punctate hypodensity within the right lobe of the liver is too
small to characterize, but likely represents a cyst or biliary hamartoma
(series 5, image 18). The liver demonstrates homogenous attenuation
throughout. There is no suspicious hepatic lesion. There is no evidence of
intrahepatic or extrahepatic biliary dilatation. The gallbladder is within
normal limits.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions. An accessory spleen is seen at the hilum.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: Within the upper pole of the left kidney, there are two thick-walled
lesions measuring 2.0 x 1.5 cm and 1.4 x 1.2 cm with central hypoattenuation
(series 7, image 26, 28), which given the clinical history of pyelonephritis,
are compatible with abscesses. A 9 mm hypodensity within the interpolar
region of the left kidney is too small to characterize, but likely represents
a simple cyst (series 7, image 30). Otherwise, the kidneys are of normal and
symmetric size with normal nephrogram. There is no evidence of
hydronephrosis. There is no perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement throughout. The colon and
rectum are within normal limits. The appendix is normal.
PELVIS: Circumferential wall thickening of the bladder, greater than expected
for the degree of distension, likely representing cystitis. There is no free
fluid in the pelvis.
REPRODUCTIVE ORGANS: The visualized reproductive organs are unremarkable.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. No atherosclerotic disease
is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. Two thick-walled lesions measuring 2.0 x 1.5 cm and 1.4 x 1.2 cm with
small central fluid components in the upper pole of the left kidney, which
given the clinical history of pyelonephritis, are compatible with abscesses.
2. Mild circumferential wall thickening of the bladder, greater than expected
for the degree of distension, likely representing cystitis.
NOTIFICATION: The findings were discussed with ___, M.D. by
___, M.D. on the telephone on ___ at 1:30 pm, 2 minutes
after discovery of the findings. The impression above was also entered by Dr.
___ on ___ at 15:27 into the Department of Radiology
critical communications system for direct communication to the referring
provider.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old woman with fevers, r/o infiltrate// fevers r/o
infiltrate
COMPARISON: Chest radiographs from ___, most recently ___
FINDINGS:
PA and lateral views of the chest provided.
The lungs are fully expanded and clear. The cardiomediastinal contours and
pleural surfaces are normal.
IMPRESSION:
1. No acute cardiopulmonary abnormality.
NOTIFICATION: The findings were discussed with Ms. ___, RN by ___
___, M.D. on the telephone on ___ at 11:30 am, 2 minutes after
discovery of the findings.
Radiology Report
EXAMINATION: RENAL U.S.
INDICATION: ___ year old woman p/w fever found to have L renal abscesses on
CT// eval renal abscess. Would like to know if can be seen via U/S for
followup ultrasound as opposed to a f/u CT
TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were
obtained.
COMPARISON: CT ___
FINDINGS:
The right kidney measures 10.0 cm. The left kidney measures 11.2 cm. There is
no hydronephrosis or stones bilaterally. The right kidney has normal cortical
echogenicity and corticomedullary differentiation. There is a circumferential
echogenic irregularity or deformity in the upper pole of the left kidney which
could correspond to the CT finding from ___.
The bladder is moderately well distended and normal in appearance.
IMPRESSION:
1. E chogenic area in the upper pole of the left kidney consistent with
pyelonephritis, no evidence of fluid collection. Please note that CT is more
sensitive for detection of abscess formation.
Gender: F
Race: ASIAN
Arrive by WALK IN
Chief complaint: Dysuria, L Flank pain
Diagnosed with Tubulo-interstitial nephritis, not spcf as acute or chronic
temperature: 97.8
heartrate: 98.0
resprate: 16.0
o2sat: 99.0
sbp: 103.0
dbp: 65.0
level of pain: 7
level of acuity: 3.0 | Outpatient Providers: ___ is a ___ yo F w/ a hx of asthma who
presented w/ fevers and L
sided flank pain concerning for pyelonephritis and CT scan
revealing for 2 small renal abscesses.
ACUTE/ACTIVE PROBLEMS
======================
# L sided pyelonephritis c/b 2 small renal abscesses
The pt presented with fevers for 7 days and left flank pain for
3 days concerning for pyelonephritis. A CT scan done in the ED
revealed two small abscesses on the L kidney (2.0 x 1.5 cm and
1.4 x 1.2 cm) so she was admitted to medicine service and
started on empiric IV ceftriaxone. She was evaluated by urology
who felt that the abscesses were too small for drainage and
recommended medical management. Lab results from several days
prior to admission were retrieved from her doctor's office in ___
and notable for urine cultures growing pan sensitive e. coli.
She was then transitioned to oral ciprofloxacin. She remained
afebrile without a leukocytosis throughout her admission and
demonstrated clinical improvement. She was discharged on oral
ciprofloxacin with plans for a ___.
A renal US was done while inpatient but the abscesses were
visualized. It is therefore recommended that she have a follow
up CT scan to assess for resolution of the abscesses.
# Headache
The pt also complained of a headache. Her neuro exam was
non-focal and reassuring. She had no meningismus and there was
was low concern for meningitis. The pt's headache resolved with
Tylenol and ibuprofen.
CHRONIC/STABLE PROBLEMS
=========================
# History of asthma
The pt reported that she was not on any inhalers at home, and
she was breathing comfortably on room air.
TRANSITIONAL ISSUES
====================
[] The pt should have a follow up CT scan in ___ weeks to
assess for resolution of renal abscesses.
- The pt already has a follow up appointment with her new PCP on
___.
- She should continue ciprofloxacin 500mg BID until ___ for
a total of a 3 week course with determination of need for
further antibiotics pending follow-up CT scan prior to
completion of antibiotic course.
# Code status: Full, presumed
# Contact: ___
# Relationship: sister
# Phone: ___
[x]>30 minutes spent on discharge planning and care coordination
on day of discharge |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Lyrica
Attending: ___.
Chief Complaint:
Foreign Body Ingestion
Major Surgical or Invasive Procedure:
Endoscopy with retrieval of foreign body
History of Present Illness:
___ yo F with seizure disorder, mental retardation, depression,
psychosis and multiple suicide attempts presents to ER from her
group psychiatric facility after she reports swallowing a
toothbrush cover ___ in size) in an attempt to kill
herself. Patient was recently hospitalized at ___
for what were ultimately felt to be pseudo-seizures and was
discharged to her current group psychiatric facility (___) on
___. She has a history per report of attention seeking
behaviors but does have significant depression per report.
At around 11 am on the day of admission, the patient reported
swallowing a toothbrush cover (the kind used to cover bristles
during travel). Some reports say this was followed by some
emesis with small amount of blood, but she denies this upon
interview on the floor. Since then she has not felt as though
there is anything stuck in her throat, esophagus, or stomach and
is able to manage her secretions without issue. She does
complain of vague abdominal pain in her LLQ (though in the ED
she complained of LUQ pain). No fevers or chills. No SOB or
chest pain. Per her report she has not swallowed anything like
this before. She has had 1 BM since swallowing the toothbrush
cover and denies any blood in it.
On arrival to the ED, VS were 97.9, 100, 138/86, 16, 99% RA.
Exam was unremarkable, rectal exam guaiac negative. Plain films
of abdomen and chest were obtained, but the foreign body was not
seen. LLE US was also obtained because she complained of calf
pain, which was negative for DVT. Labs unremarkable. GI consult
obtained, recommended admission to medicine with plan for EGD
under MAC anesthesia in the AM.
On arrival to the floor, patient is sleeping comfortably. Upon
awakening, she reports that she still has some pain in her LLQ.
No other new symptoms.
REVIEW OF SYSTEMS:
Denies fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, nausea, vomiting, diarrhea, constipation, BRBPR,
melena, hematochezia, dysuria, hematuria.
All other 10-system review negative in detail.
Past Medical History:
Depression
Seizure disorder
Mental retardation
Obesity
s/p CCY
Social History:
___
Family History:
Non-contributory
Physical Exam:
ADMISSION:
VS T 98.0, BP 138/80, HR 74, RR 18, O2 sat 96% RA
GEN Obese young woman lying in bed, no acute distress
HEENT NCAT MMM EOMI sclera anicteric, OP clear
NECK supple, no JVD
PULM Good aeration, CTAB no wheezes, rales, ronchi
CV RRR normal S1/S2, no mrg
ABD soft, obese, ND. Minimally tender to palpation along left
abdomen/LLQ. normoactive bowel sounds, no r/g
EXT WWP 2+ pulses palpable bilaterally, no c/c/e
NEURO CNs2-12 intact, motor function grossly normal
SKIN no ulcers or lesions
DISCHARGE:
VS - 98.3 ___ 20 ___ ra
GEN Obese young woman lying in bed, no acute distress
HEENT NCAT MMM EOMI sclera anicteric, OP clear
NECK supple, no JVD
PULM Good aeration, CTAB no wheezes, rales, ronchi
CV RRR normal S1/S2, no mrg
ABD soft, obese, ND. no ttp. normoactive bowel sounds, no r/g
EXT WWP 2+ pulses palpable bilaterally, no c/c/e
NEURO CNs2-12 intact, motor function grossly normal, active SI,
though no distress. Mood depressed
SKIN no ulcers or lesions
Pertinent Results:
LABS:
___ 10:00PM BLOOD WBC-8.4 RBC-4.42 Hgb-12.5 Hct-38.1 MCV-86
MCH-28.4 MCHC-32.9 RDW-13.5 Plt ___
___ 10:00PM BLOOD Neuts-58.8 ___ Monos-3.9 Eos-2.2
Baso-0.5
___ 10:00PM BLOOD ___ PTT-29.8 ___
___ 10:00PM BLOOD Glucose-77 UreaN-9 Creat-0.7 Na-141 K-4.2
Cl-107 HCO3-27 AnGap-11
___ 10:00PM URINE UCG-NEGATIVE
CXR: No radiopaque foreign body. Possible mild pulmonary edema
with
appearance likely accentuated due to low lung volumes and
patient body
habitus.
AXR: No visualized radiopaque foreign body.
RLE U/S: No evidence of deep venous thrombosis in the right
lower
extremity.
EGD:
- Normal mucosa in the esophagus
- Plastic foreign body in the stomach status post successful
foreign body removal.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from webOMR.
1. Atorvastatin 40 mg PO DAILY
2. Benztropine Mesylate 1 mg PO Q12H:PRN extrapyramidal symptoms
3. Haloperidol 10 mg PO TID:PRN agitation
4. DiphenhydrAMINE 25 mg PO Q8H:PRN extrapyramidal sxs
5. Lorazepam 2 mg PO Q4H:PRN anxiety, agitation
6. LaMOTrigine 100 mg PO QAM Start: In am
7. LaMOTrigine 125 mg PO QPM
8. Calcium Carbonate Dose is Unknown PO Frequency is Unknown
9. Vitamin D Dose is Unknown PO Frequency is Unknown
10. Risperidone 4 mg PO HS
11. traZODONE 100 mg PO HS
12. Zonisamide 200 mg PO HS
13. Ibuprofen 400 mg PO Q6H:PRN pain
14. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Atorvastatin 40 mg PO DAILY
2. Benztropine Mesylate 1 mg PO Q12H:PRN extrapyramidal symptoms
3. DiphenhydrAMINE 25 mg PO Q8H:PRN extrapyramidal sxs
4. Haloperidol 10 mg PO TID:PRN agitation
5. LaMOTrigine 100 mg PO QAM
6. LaMOTrigine 125 mg PO QPM
7. Lorazepam 2 mg PO Q4H:PRN anxiety, agitation
8. Risperidone 4 mg PO HS
9. traZODONE 100 mg PO HS
10. Zonisamide 200 mg PO HS
11. Ibuprofen 400 mg PO Q6H:PRN pain
12. Multivitamins 1 TAB PO DAILY
13. Vitamin D 400 UNIT PO DAILY
14. Calcium Carbonate 500 mg PO TID:PRN constipation
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Foreign Body Ingestion
Mental Retardation
Depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
CHEST, TWO VIEWS: ___.
HISTORY: ___ female with psychiatric history, potentially swallowed
toothpaste cap.
FINDINGS: Frontal and lateral views of the chest. No prior. Low lung
volumes and large patient body habitus somewhat limited exam. There is no
large confluent consolidation. There is crowding of the pulmonary vascular
markings with indistinct vascular markings. No large confluent consolidation.
No large effusion is identified. Cardiac silhouette is within normal limits.
There is no radiopaque foreign body.
IMPRESSION: No radiopaque foreign body. Possible mild pulmonary edema with
appearance likely accentuated due to low lung volumes and patient body
habitus.
Radiology Report
ABDOMEN, MULTIPLE VIEWS: ___.
HISTORY: ___ female with psych history, may have swallowed toothpaste
cap. Question foreign body.
FINDINGS: Three views of the abdomen were evaluated. No prior. There is a
nonobstructive bowel gas pattern identified with gas and stool throughout the
colon. Surgical clips in the right upper quadrant suggest prior
cholecystectomy. There is no other radiopaque foreign body identified.
IMPRESSION: No visualized radiopaque foreign body.
Radiology Report
INDICATION: Patient initially presenting to the emergency department for
swallowing a plastic toothpaste cap, now with right leg pain and swelling.
TECHNIQUE: Right lower extremity Doppler ultrasound.
COMPARISON: None available.
FINDINGS: Grayscale and Doppler sonograms of the right common femoral,
superficial femoral and popliteal veins were performed. There is normal
compressibility, flow and augmentation. The calf veins were not visualized.
Soft tissue swelling of the right calf is noted with no underlying fluid
collection identified.
IMPRESSION: No evidence of deep venous thrombosis in the right lower
extremity.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: SWALLOWED FB
Diagnosed with FOREIGN BODY IN STOMACH, FB ENTERING OTH ORIFICE, SCHIZOAFFECTIVE-UNSPEC
temperature: 97.9
heartrate: 100.0
resprate: 16.0
o2sat: 99.0
sbp: 138.0
dbp: 86.0
level of pain: 10
level of acuity: 3.0 | ___ yo F with seizure disorder, mental retardation, depression,
psychosis and multiple suicide attempts presents to ER from her
group psychiatric facility after she reports swallowing a
toothbrush cover ___ in size) in an attempt to kill
herself. Successfully removed via EGD from stomach and dc-ed
back to ___ after medical clearance.
# Foreign body ingestion: no signs/symptoms of esophageal
obstruction, gastric outlet obstruction, or other trauma from
the foreign body at ___ time. GI was not sure that it would
pass on its own through the pylorus of the stomach, so she
underwent EGD under MAC and were able to retrieve the object
form the stomach. Did well post procedure and was dc-ed back to
___.
# Suicide attempt: per patient, she swallowed the toothbrush
cover because she "wants to die". Has had previous suicide
attempts, but denies ever having HI. Active SI in AM but no
distress and or agitations. Patient under ___. 1:1 sitter
and suicide precautions were in place
# Depression/Pyschosis: depressed. We continued current home
psychiatric meds (med list above confirmed with ___)
# Seizure disorder: stable. We continued home anti-seizure
medications |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
abdominal pain x2 wks
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Ms. ___ is a ___ lady with COPD, DM2/neuropathy, HTN, HL,
h/o CVA and multiple admissions for abdominal pain who presented
to the ED with abdominal pain. She describes 2 weeks of pain in
LLQ that she describes as a "burning." She reports that it
radiates towards her back and to her L shoulder. She denies
vomiting, chest pain, diarrhea/constipation. No fevers. Of note,
she was admitted 3 months ago for similar symptoms with vomiting
and was treated for h.pylori infection. She reports that she
went to her PCP who wanted her sent to the ED for a CT scan.
.
In the ED, initial VS were: 10 97.9 72 146/72 20 100%RA. Labs
were unremarkable but abdominal pain persisted, with LLQ
guarding but no rebound. There was concern for diverticulitis so
she was given IV Cipro/Flagyl. CT abdomen revealed
diverticulosis but no diverticulitis; no cause fo rthe abdominal
pin was identified. She was given Morphine 2mg IV and was
admitted to Medicine for pain control/observation.
.
On the floor, patient is comfortable. Her pain is down to a 2.
She declines further interview and asks for a soda and some
sleep.
.
REVIEW OF SYSTEMS:
Denies fever, chills. No nausea, vomiting, diarrhea,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
No chest pain.
Past Medical History:
-Dyslipidemia
-Hypertension
-IDDM Type 2 (poorly controlled)
-Old "right-sided stroke with residual left-sided weakness" as
per OMR.
-COPD
-Peripheral neuropathy
-lung nodule
-gallbladder polyp
-recently treated for H. pylori in ___
Social History:
___
Family History:
Mother- died at age ___, had CAD, DM2, HTN
Father- died at ___ of possible laryngeal cancer
Notable for BPAD in a daughter.
Physical Exam:
Admission PEx:
VS - Temp 97.1F, BP 131/60, HR 65, R 16, O2-sat 98% RA
GENERAL: no a cute distress
HEENT: NCAT. Sclera anicteric. PERRL, EOMI.
NECK: Supple. No JVD
CARDIAC: RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3
or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM.Very mild TTP of LLQ with no
guarding and no rebound.
EXTREMITIES: No c/c/e.
SKIN: No rash
.
.
.
Discharge PEx:
VITALS: ___ 115/71 69 16 99%RA
BS 164
GENERAL: no acute distress
HEENT: NCAT. Sclera anicteric. PERRL, EOMI.
NECK: Supple. No JVD
CARDIAC: RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3
or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM.Very mild TTP of LLQ with no
guarding and no rebound.
EXTREMITIES: No c/c/e.
SKIN: No rash
Guaiac: negative
Pertinent Results:
Labs on admission:
___ 03:00PM BLOOD WBC-6.9 RBC-4.32 Hgb-13.3 Hct-39.4 MCV-91
MCH-30.9 MCHC-33.8 RDW-12.6 Plt ___
___ 03:00PM BLOOD Neuts-59.0 ___ Monos-2.9 Eos-1.7
Baso-0.3
___ 03:00PM BLOOD Glucose-276* UreaN-9 Creat-1.0 Na-140
K-3.7 Cl-104 HCO3-25 AnGap-15
___ 03:00PM BLOOD ALT-14 AST-19 CK(CPK)-73 AlkPhos-103
___ 03:00PM BLOOD Lipase-15
___ 03:00PM BLOOD Albumin-4.3
___ 07:24PM BLOOD Lactate-1.4
___ 03:00PM BLOOD CK-MB-2 cTropnT-<0.01
___ 05:00PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-1000 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
Micro:
Blood cultures ___: negative x2
.
.
.
Imaging:
EKG: Sinus rhythm with atrial premature depolarizations. Left
axis deviation. Left anterior fascicular block. Non-diagnostic
repolarization abnormalities. Compared to the previous tracing
of ___ there is no significant change.
.
CT Abd/Pelvis: The included portions of the lung bases are
unremarkable.
The liver, gallbladder, pancreas, adrenal glands, and kidneys
are grossly
unremarkable. The spleen contains a hypodensity, too small to
characterize
(601B:35). Loops of small and large bowel are normal in size and
caliber.
There is extensive colonic diverticulosis without evidence of
diverticulitis.
The bladder, distal ureters and uterus appear normal. Distal
loops of large
bowel and rectum are normal in size and caliber with again note
of
diverticulosis. The appendix is normal.
No free air, free fluid, or lymphadenopathy is seen.
There is stable deformity of the superior endplate at L5. No
concerning
osseous lesion is seen.
IMPRESSION: No acute findings to explain pain. Diverticulosis
without
evidence of diverticulitis.
Medications on Admission:
ALBUTEROL SULFATE - 90 mcg HFA Aerosol Inhaler - 1 puff inhaled
as needed as needed for for shortness of breath, wheezing
ATORVASTATIN [LIPITOR] - 20 mg Tablet - 1 Tablet(s) by mouth
daily
FLUTICASONE-SALMETEROL [ADVAIR DISKUS] - 250 mcg-50 mcg/Dose
Disk
with Device - 1 puff twice a day
FUROSEMIDE - 20 mg Tablet - 1 Tablet(s) by mouth daily
HANDIHALER - - use with Spiriva daily For spiriva
INSULIN DETEMIR [LEVEMIR FLEXPEN] - 100 unit/mL (3 mL) Insulin
Pen - take 28 units QAM
INSULIN LISPRO [HUMALOG] - 100 unit/mL Solution - bid as
directed
per sliding scale
LISINOPRIL - 5 mg Tablet - 1 Tablet(s) by mouth daily
METFORMIN - 1,000 mg Tablet - 1 and ___ Tablet(s) by mouth in
Am,
1 tab in pm
NORTRIPTYLINE - 10 mg Capsule - 1 Capsule(s) by mouth daily
OMEPRAZOLE - 20 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s)
by mouth twice a day
TIOTROPIUM BROMIDE [SPIRIVA WITH HANDIHALER] - 18 mcg Capsule,
w/Inhalation Device - 1 cap inhale daily
TRAZODONE - 50 mg Tablet - ___ Tablet(s) by mouth daily as
needed for for sleep
ASPIRIN - 325 mg Tablet - 1 Tablet(s) by mouth daily
MULTIVITAMIN [CHEWABLE-VITE] - Tablet, Chewable - 1 Tablet(s)
by mouth daily
Discharge Medications:
1. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
___ Puffs Inhalation Q6H (every 6 hours) as needed for
SOB/wheezing.
2. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO every six
(6) hours.
Disp:*100 Tablet(s)* Refills:*2*
4. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation BID (2 times a day).
5. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
6. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
7. insulin detemir 100 unit/mL (3 mL) Insulin Pen Sig: Twenty
Eight (28) units Subcutaneous QAM: As directed previously prior
to your hospitalization.
8. insulin lispro 100 unit/mL Solution Sig: AS DIR Subcutaneous
twice a day: AS DIRECTED by your sliding scale, prior to your
hospitalization.
9. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. metformin 1,000 mg Tablet Sig: AS DIRECTED Tablet PO once a
day: 1.5 tablets in AM, 1 tablet in ___.
11. nortriptyline 10 mg Capsule Sig: One (1) Capsule PO once a
day.
12. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
13. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
14. trazodone 50 mg Tablet Sig: AS DIR Tablet PO QHS: PRN: 0.5-1
mg at night as needed for sleep.
15. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. senna 8.6 mg Tablet Sig: One (1) Tablet PO once a day: For
constipation.
Disp:*30 Tablet(s)* Refills:*1*
17. Colace 50 mg Capsule Sig: One (1) Capsule PO once a day: As
needed for constipation.
Discharge Disposition:
Home
Discharge Diagnosis:
Abdominal pain of unclear etiology
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Left upper quadrant pain.
TECHNIQUE: Multidetector helical CT scan of the abdomen and pelvis was
obtained after the administration of 100 mL IV Optiray contrast. Coronal and
sagittal reformations were prepared.
COMPARISON: CT examination dated ___.
FINDINGS: The included portions of the lung bases are unremarkable.
The liver, gallbladder, pancreas, adrenal glands, and kidneys are grossly
unremarkable. The spleen contains a hypodensity, too small to characterize
(601B:35). Loops of small and large bowel are normal in size and caliber.
There is extensive colonic diverticulosis without evidence of diverticulitis.
The bladder, distal ureters and uterus appear normal. Distal loops of large
bowel and rectum are normal in size and caliber with again note of
diverticulosis. The appendix is normal.
No free air, free fluid, or lymphadenopathy is seen.
There is stable deformity of the superior endplate at L5. No concerning
osseous lesion is seen.
IMPRESSION: No acute findings to explain pain. Diverticulosis without
evidence of diverticulitis.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: LUQ PAIN
Diagnosed with ABDOMINAL PAIN LLQ, DIABETES UNCOMPL ADULT
temperature: 97.9
heartrate: 72.0
resprate: 20.0
o2sat: 100.0
sbp: 146.0
dbp: 72.0
level of pain: 10
level of acuity: 3.0 | Ms. ___ is a ___ F with COPD, DM2/neuropathy, HTN and HL who
presents for the fourth time this year due to chronic abdominal
pain.
.
#. Epigastric pain/left sided abd pain: unclear etiology;
patient describes ___ week history of epigastric pain that wraps
down the left side of the abdominal/pelvic area. Initially
thought to be diverticulitis but abd/pelvic CT not suggestive of
any acute process. History makes mesenteric ischemia less
likely, also guiaic negative. Considered pancreatitis but no
lipase and clinical picture is not consistent. No significant
EtOH abuse or other substance abuse. DM2 is poorly controlled
but this presentation is not typical for DM2 gastroparesis as
pain does not change with meals. no early satiety. This may
represent PUD (esp given H.pylori was positive in ___ vs GERD
(esp given hiatal hernia). EGD in ___ revealed chemical-type
gastritis so this is possible but unclear what meds/ingestions
could be causing this besides ASA 325. Cardiac etiology very
unlikely; EKG is unchanged and cardiac enzymes negative x2. Pain
improved with tylenol and workup/management of recurrent
abdominal/epigastric pain will be continued as outpatient.
Aspirin was decreased to 81mg daily and patient was instructed
to use tylenol prn pain and senna/colace to promote regular
bowel movements. Recommend consideration of repeat H pylori
testing (breath test) should symptoms persist.
.
#. Hypertension: BP reasonably controlled. Will continue
lisinopril and lasix
.
#. DM2: poorly controlled due to compliance. Patient will be
restarted on home regimen.
-Continue aspirin, statin and ACE
.
#. COPD: stable; continue home inhalers
.
. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / Shellfish / Nafcillin / Coumadin
Attending: ___.
Chief Complaint:
fever and GPC bacteremia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ ___ gentleman with a PMH of ESRD on HD
from FSGS, aortic valve MSSA endocarditis (___), s/p
bioprosthetic AVR (___), s/p St. ___ mechanical AVR (___),
on aspirin/Plavix (had significant bleeding complications on
warfarin), now presenting with fever to 104.8 and blood culture
positive for GPCs. Pt developed fever to 102, chills on ___.
Blood cx was obtained, and pt was given vancomycin at ___ on
the same day. Fever peaked to 104.8 subsequent day, with nausea,
vomiting, diarrhea. Blood cutlure grew GPC today, and pt asked
to come to the ED. Last home HD session ___. N/V/D only
lasted a day and then resolved. Pt actually feels much better
now. He is s/p two doses of vanco one and ___ and the second
in the ED prior to admission. He underwent a TEE on ___ out of
concern for repeat endocarditis when he initially developed
fevers which was neg for vegetations. He is on home HD and
administers HD to himself 5 times per wk on days of his
choosing.
In the ED, initial VS were: 97 93 131/69 18 100% RA. Physical
exam was notable for a precordial lift and ___ systolic ejection
murmur with mechanicla S2. Labs were remarkable for: WBC 4.7
with 22.7% eos, H/H 8.7/28.0; ALT 84, AST 56, Alb 3.4; BUN/Cr
81/12.2; Mg 2.2, P 6.9; lactate 0.6. Blood cultures x2 were
sent. CXR PA/lat showed no acute cardiopulmonary process.
Patient was given vancomycin 1g IV. VS on transfer: 98.5 79
117/68 16 100%.
On arrival to the floor, pt was comfortably walking around room
in NAD. He was able to answering all questions without
difficulty and stated he was feeling back to his normal self.
REVIEW OF SYSTEMS:
(+) Per HPI
(-) Denies recent weight loss or gain. Denies headache, sinus
tenderness, rhinorrhea or congestion. Denies cough, shortness of
breath, or wheezing. Denies chest pain, chest pressure,
palpitations, or weakness. Denies constipation, abdominal pain.
Denies dysuria, frequency, or urgency. Denies arthralgias or
myalgias.
Past Medical History:
# ESRD on HD ___, ___ FSGS on renal bx in ___
# L AVF created ___ complicated by stenosis s/p percutaneous
angioplasty ___ and ___
# Aortic valve endocarditis with MSSA s/p bioprosthetic AVR
___, presumed secondary to HD line infection
- c/b ___ abscess that recurred after his initial
# AVR requiring homograft valve and aortic root replacement with
reimplantation of his coronary arteries (___)
- Completed 6 week course of nafcillin on ___
- subsequently maintained on dicloxacillin through ___.
- recurrent MSSA bacteremia with presumed recurrent endocarditis
in ___ treated with 6 weeks of rifampin and cefazolin with 2
wks
of gent
- Porcine valve replaced with ___ valve on ___ c/b
intrathoracic hematoma and hemothorax while on coumadin, now
maintained on ASA and Plavix
Social History:
___
Family History:
mother - breast ca at ___, survivor, aunt - died of MI at ___, no
other family hx of renal disease, no DM or other CA in the
family
Physical Exam:
ADMISSSION PHYSICAL EXAM:
VS: 98.7, 118/70, 88, 16, 98% RA
GENERAL: well appearing, NAD
HEENT: NC/AT, EOMI, sclerae anicteric, MMM
NECK: supple, no LAD, JVD: flat
LUNGS: CTA bilat, no r/rh/wh, good air movement, resp unlabored,
no accessory muscle use
HEART: RRR, mechanical heart murmur, nl ___, well healed
sternotomy scar
ABDOMEN: normal bowel sounds, soft, ___,
no rebound or guarding, no masses
EXTREMITIES: no edema, 2+ pulses radial and dp, fistula in LUE
with palpable thrill
NEURO: awake, A&Ox3, CNs ___ grossly intact, muscle strength
___ throughout, sensation grossly intact throughout
.
.
DISCHARGE PHYSICAL EXAM:
VS: 98.6, ___, 100% RA pain ___
GENERAL: well appearing, NAD, pleasant, thin
HEENT: NC/AT, EOMI, sclerae anicteric, MMM
NECK: supple, no LAD, JVD: flat
LUNGS: CTA bilat, no r/rh/wh, good air movement, resp unlabored,
no accessory muscle use
HEART: RRR, loud mechanical heart sound heard without
stethoscope, ___ SEM heard best at apex, nl ___, well healed
sternotomy scar
ABDOMEN: normal bowel sounds, soft, ___,
no rebound or guarding, no masses, mutiple surgical scars
EXTREMITIES: no edema, 2+ pulses radial and dp, fistula in LUE
with palpable thrill
NEURO: awake, A&Ox3, CNs ___ grossly intact, muscle strength
___ throughout, sensation grossly intact throughout
SKIN: no rashes, no splinter hemorrhages, no ___ lesions or
nodes, some new excoriations from itching on previous day
Pertinent Results:
Admission Labs:
___ 07:40PM BLOOD ___
___ Plt ___
___ 07:40PM BLOOD ___
___
___ 08:00AM BLOOD ___
___
___
___ 12:23PM BLOOD Ret ___
___ 06:20PM BLOOD ___
___ 07:40PM BLOOD ___
___
___ 07:40PM BLOOD ___
___ 08:10AM BLOOD ___
___ 07:40PM BLOOD ___
___
___ 07:40PM BLOOD Hapto-<5*
___ 12:23PM BLOOD ___
___ 08:10AM BLOOD ___
___ 08:10AM BLOOD ___
___ LDLmeas-<50
.
.
___ 08:10AM BLOOD ___
___ 08:00AM BLOOD HIV ___
___ 08:10AM BLOOD ___
___ 07:48PM BLOOD ___
___ 08:10AM BLOOD STRONGYLOIDES ___
___ 08:00AM BLOOD SCHISTOSOMA ___
Discharge Labs:
___ 08:00AM BLOOD ___
___ Plt ___
___ 08:00AM BLOOD ___
___
___ 08:00AM BLOOD ___
___
___ 08:10AM BLOOD ___ LD(LDH)-569* CK(CPK)-52
___ 08:00AM BLOOD ___
Micro:
___ STOOL OVA + ___ INPATIENT
___ BLOOD CULTURE Blood Culture, ___
INPATIENT
___ BLOOD CULTURE Blood Culture, ___
INPATIENT
___ BLOOD CULTURE Blood Culture, ___
INPATIENT
___ BLOOD CULTURE Blood Culture, ___
INPATIENT
___ BLOOD CULTURE Blood Culture, ___ INPATIENT
___ BLOOD CULTURE Blood Culture, ___ INPATIENT
___ BLOOD CULTURE Blood Culture, ___ INPATIENT
___ BLOOD CULTURE Blood Culture, ___ INPATIENT
___ BLOOD CULTURE Blood Culture, ___ EMERGENCY
WARD
___ BLOOD CULTURE Blood Culture, ___ EMERGENCY
WARD
.
.
___ CXR: IMPRESSION: No acute cardiopulmonary process. No
significant interval change.
.
___ ECG: Sinus rhythm. Left atrial abnormality. Right
___ block pattern Delayed R wave transition in the
precordial leads. Cannot exclude a prior anteroseptal myocardial
infarction. Compared to the previous tracing of ___ the
rate is slightly faster. Otherwise, no diagnostic change.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 325 mg PO DAILY
2. Nephrocaps 1 CAP PO DAILY
3. Lanthanum 1000 mg PO TID W/MEALS
4. Fish Oil (Omega 3) 1000 mg PO BID
5. Clopidogrel 75 mg PO DAILY
6. Renagel *NF* 2400 mg Other TID with meals
7. Ascorbic Acid ___ mg PO DAILY
8. Vitamin E 1000 UNIT PO DAILY
9. Calcitriol 0.5 mcg PO EVERY OTHER DAY
10. Lisinopril 20 mg PO DAILY
hold for sbp <100
11. Metoprolol Succinate XL 25 mg PO DAILY
12. Vitamin D ___ UNIT PO DAILY
Discharge Medications:
1. Ascorbic Acid ___ mg PO DAILY
2. Aspirin 325 mg PO DAILY
3. Calcitriol 0.5 mcg PO EVERY OTHER DAY
4. Clopidogrel 75 mg PO DAILY
5. Fish Oil (Omega 3) 1000 mg PO BID
6. Lanthanum 1000 mg PO TID W/MEALS
7. Lisinopril 20 mg PO DAILY
8. Metoprolol Succinate XL 25 mg PO DAILY
9. Nephrocaps 1 CAP PO DAILY
10. Renagel *NF* 2400 mg Other TID with meals
11. Vitamin D ___ UNIT PO DAILY
12. CefazoLIN 2 g IV POST HD ___
13. CefazoLIN 2 g IV POST HD ___
14. CefazoLIN 3 gm IV POST HD ___
15. Vitamin E 1000 UNIT PO DAILY
16. Outpatient Lab Work
ICD9 790.7 Bacteremia
Please draw WEEKLY CBC, CHEM10, LFTS and fax to the Attn: Dr.
___. All laboratory results should be faxed to the
___ R.N.s at ___. All questions
regarding outpatient parenteral antibiotics should be directed
to the ___ R.N.s at ___ or to the
___ ID fellow when the clinic is closed.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis: MSSA bacteremia, eosinophilia, ESRD on HD
Secondary diagnosis: CHF, CAD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Recent fever and Gram positive cocci in blood.
TECHNIQUE: Frontal and lateral views of the chest.
COMPARISON: ___.
FINDINGS:
The lungs are clear without focal consolidation. No pleural effusion or
pneumothorax is seen. The cardiac and mediastinal silhouettes are stable.
The patient is status post median sternotomy. Vascular stenting appears
stable in position.
IMPRESSION:
No acute cardiopulmonary process. No significant interval change.
Gender: M
Race: HISPANIC/LATINO - PUERTO RICAN
Arrive by WALK IN
Chief complaint: +VE BLC
Diagnosed with BACTEREMIA NOS, FEVER, UNSPECIFIED, END STAGE RENAL DISEASE, HEART VALVE REPLAC NEC
temperature: 97.0
heartrate: 93.0
resprate: 18.0
o2sat: 100.0
sbp: 131.0
dbp: 69.0
level of pain: 0
level of acuity: 2.0 | Mr. ___ is a ___ ___ gentleman with a PMH of ESRD on HD
from FSGS, aortic valve MSSA endocarditis (___), s/p
bioprosthetic AVR (___) with repair, s/p St. ___ mechanical
AVR (___), on aspirin/Plavix now presenting with MSSA
bacteremia.
# GPC bacteremia: Patient presented with outside dialysis blood
cultures positive for MSSA. Started on vancomycin and switched
to cefazolin with HD 2g ___. He will get
HD at the outpatient ___ the duration of his antibiotics
treatment of 6 weeks, until ___. He will follow up with ___
as well in 2 and 6 weeks.
.
.
# History of endocarditis s/p mechanical valve: Developed
hematomas with warfarin anticoagulation now maintained only on
Full strength ASA and Plavix daily. No current evidence of
endocarditis. Continued on home aspirin and Plavix.
.
# ESRD on HD: pt is on home HD 5 days per wk which he
administers himself on the days he chooses to. HD 3x week while
in house and for course of antibiotics. Continued on sevelamer
and nephro caps.
.
.
# Eosinophilia: Significantly elevated, and this is not noted on
previous admissions. Unclear etiology as infection is of
bacterial source. Unlikely there is additional infection,
however cannot rule this out without further investigation. Per
heme/onc, only correlation is with home HD initiation however
this is far from diagnostic. He will be followed by hematology,
PCP, HD nurse and nephrologist for this. Continue to monitor in
the outpatient setting.
.
.
#CHF - Last stress echo performed ___ which showed EF 40%.
Pt had ischemic changes with exercise which forced the stress to
be stopped. It was recommended that he have a diagnostic cath
which will be arranged with Dr. ___ infection is
cleared. Continued on lisinopril, ASA, Plavix, metoprolol.
Consider outpatient initiation of statin.
.
# Anemia - Chronic, at baseline. No evidence of bleeding during
this admission.
.
# Thrombocytopenia - In the setting of infection, this is known
to occur in this patient and was uptrending upon discharge.
Recommend repeating as outpatient to confirm resolution. There
is evidence of low grade hemolysis which could be related to his
valve or HD, which will be investigated by HD nurse,
___, and the patient. The patient remained
hemodynamically stable without bleeding or evidence of DIC.
.
.
# Transaminitis- AST/ALT mildly elevated. Pt has been checked in
the past for hepatitis on several occassions and has been
negative. Would recommend repeat as outpatient.
.
# Hypertension: continued home regimen of lisinopril
.
.
Transitional Issues:
- f/u blood cultures: to be followed by PCP, ___
- Davita for results: RN ___
- HEALTH CARE PROXY: ___ hcp ___ friend,
___ ex wife ___
- continue anticoagulation with ASA/Plavix- repeat AST/ALT
- follow up with Dr. ___ cath, statin initiation,
cardiac follow up
- follow up with Hematology for eosinophilia
- follow up with PCP
- follow up with ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
? a cream
Attending: ___.
Chief Complaint:
Stuttering speech
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a ___ year old woman w PMH of plaquenoid
maculopathy on prednisone (and recently on cellcept), breast
cancer s/p resection, HTN, p/w acute onset stuttering x 1.5
weeks. The patient was at her sisters birthday party a week and
a
half prior top presentation, when suddenly the patient started
stuttering at the dinner table. She says she had been a little
anxious that day in terms of planning to get to the party on
time, but if anything she was more relaxed during the dinner.
She
describes that she knows what she wants to say, but has
difficulty physically forming the words when she is speaking.
Her
writing has similarly suffered, and her handwriting has gotten
worse in the past 1.5 weeks as well. She has noted no
improvement
or worsening of her symptoms. She has gotten somewhat
frustrated,
and now tends to talk less since it is difficulty for her to
speak. She is able to read ok, and understands what other people
are stayin. She has also noted she seems to be holding her fork
and her pen wrong for the last 1.5 weeks.
On neurologic review of systems, the patient endorses mild
headache since being in the ED, denies lightheadedness, or
confusion.
Denies difficulty with comprehending speech.
Denies loss of vision, diplopia, vertigo, tinnitus, hearing
difficulty, dysarthria, or dysphagia.
Denies muscle weakness.
Denies loss of sensation.
Denies bowel or bladder incontinence or retention.
Denies difficulty with gait.
On general review of systems, the patient denies fevers, rigors,
or noticeable weight loss. She does have longstanding night
sweats.
Denies chest pain, palpitations, dyspnea, or cough.
Denies nausea, vomiting, diarrhea, constipation, or abdominal
pain.
Denies dysuria or hematuria.
Denies myalgias, arthralgias, or rash.
Past Medical History:
- plaquenoid maculopathy - HTN
- breast cancer s/p resection, radiation, and chemo
- fatty liver/cirrhosis
-uveitis,on prednisone (and recently on cellcept)
Her ophthomologist is Dr. ___
___ History:
___
Family History:
Family History: no h/o stroke, seizure. no h/o rheumatologic
disease. father had stents placed in his heart, and other family
members had cancer
Physical Exam:
ADMISSION EXAM
VS 97.5 9 164/100 16 96% RA
General: NAD, lying in bed comfortably. + moon facies
Head: NC/AT, no conjunctival icterus, no oropharyngeal lesions
Neck: Supple, no nuchal rigidity, no meningismus
Cardiovascular: RRR, no M/R/G
Pulmonary: Equal air entry bilaterally, no wheezes
Abdomen: Soft, NT, ND, +BS, no guarding
Extremities: Warm, no edema, palpable pulses
Skin: No rashes or lesions
Neurologic Examination:
- Mental Status -
Awake, alert, oriented x 3. Attention to examiner easily
attained
and maintained. Concentration maintained when recalling months
backwards. Recalls a coherent history. Speech is often
stuttering, at other times it is haulting. Structure of speech
demonstrates full sentences, intact repetition, and intact
verbal
comprehension. Content of speech demonstrates intact naming
(high
and low frequency) and no paraphasias. Abnormal prosody. No
dysarthria. Verbal registration and recall ___. No apraxia. No
evidence of hemineglect. No left-right agnosia.
- Cranial Nerves -
I. not tested
II. Equal and reactive pupils (2mm to 1.5m). Visual fields were
full to finger wiggling.
III, IV, VI. smooth and full extraocular movements without
diplopia or nystagmus.
V. facial sensation was intact, muscles of mastication with full
strength
VII. face was symmetric with full strength of facial muscles
VIII. hearing was intact to finger rub bilaterally.
IX, X. symmetric palate elevation and symmetric tongue
protrusion
with full movement.
XI. SCM and trapezius were of normal strength and volume.
- Motor -
Muscule bulk and tone were normal. No pronation, no drift. No
tremor or asterixis.
Delt Bic Tri ECR IO IP Quad Ham TA Gas ___
L 5 5 ___ 5 5 5 5 5 5
R 5 5 ___ 5 5 5 5 5 5
- Sensation -
Intact to light touch, pinprick, and proprioception throughout.
- DTRs -
Bic Tri ___ Quad Gastroc
L 2 2 2 0 0
R 2 2 2 0 0
Plantar response withdrawl bilaterally.
- Cerebellar -
No dysmetria with finger to nose testing bilaterally. Good speed
and intact cadence with rapid alternating movements.
- Gait -
Normal initiation. Narrow base. Normal stride length and arm
swing. Stable without sway. No Romberg.
DISCHARGE EXAM
Unchanged with the exception of improved stuttering.
Pertinent Results:
___ 07:35AM GLUCOSE-154* UREA N-10 CREAT-0.6 SODIUM-147*
POTASSIUM-3.6 CHLORIDE-109* TOTAL CO2-30 ANION GAP-12
___ 12:19PM %HbA1c-6.3* eAG-134*
___ 09:40PM WBC-5.7 RBC-3.72* HGB-13.0 HCT-37.3 MCV-100*
MCH-35.1* MCHC-35.0 RDW-13.8
___ 07:35AM TRIGLYCER-55 HDL CHOL-83 CHOL/HDL-2.0
LDL(CALC)-74
___ 07:35AM TSH-0.35
MRI/A Brain and neck
Subacute watershed distribution infarction in the left
hemisphere.
Severe left internal carotid artery stenosis in its supraclinoid
segment
extending to the bifurcation.
No evidence of stenosis or occlusion in the neck. No evidence
of internal carotid artery stenosis by NASCET criteria.
NCHCT
1. No acute intracranial process.
2. Hypodense foci the left frontal lobe white matter, likely
the sequelae of prior small vessel ischemia.
TTE
The left atrium is elongated. No atrial septal defect or patent
foramen ovale is seen by 2D, color Doppler or saline contrast
with maneuvers. Left ventricular wall thickness, cavity size and
regional/global systolic function are normal. Quantitative (3D)
LVEF = 60%. Right ventricular chamber size and free wall motion
are normal. The diameters of aorta at the sinus, ascending and
arch levels are normal. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
stenosis or aortic regurgitation. The mitral valve appears
structurally normal with trivial mitral regurgitation. There is
no mitral valve prolapse. The estimated pulmonary artery
systolic pressure is normal. There is no pericardial effusion.
IMPRESSION: No PFO or ASD seen. Normal global and regional
biventricular systolic function.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 10 mg PO DAILY
2. anastrozole 1 mg oral DAILY
3. PredniSONE 30 mg PO DAILY
4. Vitamin D 1000 UNIT PO DAILY
5. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Mycophenolate Mofetil 1000 mg PO BID
2. Lisinopril 10 mg PO DAILY
3. Multivitamins 1 TAB PO DAILY
4. Vitamin D 1000 UNIT PO DAILY
5. anastrozole 1 mg oral DAILY
6. PredniSONE 30 mg PO DAILY
7. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet,delayed release (___) by mouth
daily Disp #*30 Tablet Refills:*0
8. Atorvastatin 40 mg PO DAILY
RX *atorvastatin 40 mg 1 tablet(s) by mouth at night Disp #*30
Tablet Refills:*0
9. Clopidogrel 75 mg PO DAILY
RX *clopidogrel 75 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
10. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID
11. Outpatient Speech/Swallowing Therapy
Patient requires outtpatient speech therapy for her mild speech
fluency issues
Discharge Disposition:
Home
Discharge Diagnosis:
Left MCA distribution ischemic infarct
Left ICA stenosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Neurological examination:
Mental status reveals very slightly halting, hesitant speech. No
anomia and repeats well.
CN examination save existing visual issues is normal.
Limb examination reveals full strength, normal saensation and no
ataxia.
Followup Instructions:
___
Radiology Report
INDICATION: Aphasia for the past one and half weeks. Evaluate for stroke or
intracranial hemorrhage.
COMPARISON: None.
TECHNIQUE: Sequential axial images were acquired through the head without
administration of intravenous contrast material. Multiplanar reformats were
performed.
TOTAL DLP: 780 mGy-cm.
CTDIvol: 55.5 mGy.
FINDINGS: There is no evidence of hemorrhage, edema, shift of normally
midline structures, hydrocephalus, or infarction. Hypodense areas within the
left frontal lobe are likely the sequelae of prior small vessel ischemia.
Prominence of the ventricles and sulci are compatible with age-related
involutional change. The visualized portions of the orbits are unremarkable.
The imaged portions of the paranasal sinuses and the mastoid air cells are
clear.
IMPRESSION:
1. No acute intracranial process.
2. Hypodense foci the left frontal lobe white matter, likely the sequelae of
prior small vessel ischemia.
Radiology Report
INDICATION: Aphasia for the past ___ weeks. Assess for infection.
COMPARISON: None.
FINDINGS: The lungs are clear. The heart size is normal. The mediastinal
contours are normal. There are no pleural effusions. No pneumothorax is
seen.
IMPRESSION: No acute cardiac or pulmonary process.
Radiology Report
HISTORY: New onset stuttering. Left frontal hypodensity on CT.
TECHNIQUE: Diffusion imaging and 3D time-of-flight MRA were performed through
the brain. Sagittal T1 weighted imaging was performed. This was followed by
axial T2, FLAIR, and gradient echo imaging. 2 dimensional time-of-flight MRA
was performed through the neck. Subsequently, 3 dimensional time-of-flight
MRA was performed during infusion of 17 cc of MultiHance intravenous contrast.
COMPARISON: Head CT ___.
FINDINGS:
The brain MRA demonstrates apparent subacute infarction in a watershed
distribution in the left deep white matter. A small focus of subacute
infarction extends to the left frontal cortex. These areas demonstrate normal
or fast diffusion and no evidence of hemorrhage. FLAIR images also
demonstrate scattered deep periventricular and subcortical white matter
hyperintensity suggesting chronic small vessel ischemia.
The MRA demonstrates severe narrowing of the supraclinoid segment of the left
internal carotid artery with poor filling of the carotid bifurcation and to
the M1 segment of the left middle cerebral artery. The A-1 segment of the
left anterior cerebral artery appears patent on the T2 weighted images, but
poorly visualized on the MRA examinations, perhaps a consequence of slow flow.
The vertebral arteries are patent bilaterally. The origins of the great
vessels appear normal.
IMPRESSION:
Subacute watershed distribution infarction in the left hemisphere.
Severe left internal carotid artery stenosis in its supraclinoid segment
extending to the bifurcation.
No evidence of stenosis or occlusion in the neck. No evidence of internal
carotid artery stenosis by NASCET criteria.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: STUTTERING
Diagnosed with CEREBRAL ART OCCLUS W/INFARCT
temperature: 97.0
heartrate: 108.0
resprate: 18.0
o2sat: 97.0
sbp: 166.0
dbp: 109.0
level of pain: 0
level of acuity: 3.0 | Ms. ___ was admitted to the stroke service for
further workup after presenting with stuttering speech for
several days. MRI brain showed several watershed-area infarcts
on the left hemisphere, accounting for her symptoms. The
etiology was determined to be a stenosed left internal carotid
artery as seen on MRA. She was therefore started on aspirin 81mg
daily and atorvastatin 40mg daily (although her lipid panel was
normal). In terms of other workup, her HbA1c was 6.3%,
attributed to being on steroids, and her TSH was wnl. Her
telemetry revealed normal sinus rhythm, and her TTE was normal.
We spoke with her ophthalmologist, and decided that Ms.
___ could restart her Cellcept (which she takes for
uveitis and was stopped in the setting of these speech
difficulties). Her ophthalmologist requested her prednisone be
continued at its current dose until ophthalmology follow up,
which is scheduled in the next few weeks. It was suggested to
her that she aim to wean off the prednisone because
hyperglycemia can cause arterial wall damage and increase stroke
risk.
She was discharged to home with a prescription for speech
therapy.
OUTSTANDING ISSUES
[ ] Started ASA and statin, and has stroke follow up.
[ ] Restarted cellcept at prior dosing
[ ] Continued prednisone at current dose
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? (x) Yes [performed
and documented by admitting resident] () No
2. DVT Prophylaxis administered by the end of hospital day 2?
(x) Yes - () No
3. Antithrombotic therapy administered by end of hospital day 2?
(x) Yes - () No
4. LDL documented (required for all patients)? (x) Yes (LDL = )
- () No
5. Intensive statin therapy administered? (x) Yes - () No [if
LDL ___ 100, reason not given: ____ ]
(intensive statin therapy = simvastatin 80mg, simvastatin
80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg, rosuvastatin
20mg or 40mg, for LDL ___ 100)
6. Smoking cessation counseling given? () Yes - (x) No [if no,
reason: (x) non-smoker - () unable to participate]
7. Stroke education given (written form in the discharge
worksheet)? (x) Yes - () No
(stroke education = personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup)
8. Assessment for rehabilitation or rehab services considered?
(x) Yes - () No [if no, reason not assessed: ____ ]
9. Discharged on statin therapy? (x) Yes - () No [if LDL ___
100 or on a statin prior to hospitalization, reason not
discharged on statin: ____ ]
10. Discharged on antithrombotic therapy? (x) Yes [Type: (x)
Antiplatelet - () Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - (x) No [if no, reason not
discharge on anticoagulation: ____ ] - (x) N/A |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
aspirin / Celebrex / Motrin / entecavir
Attending: ___.
Chief Complaint:
weakness, mumbled speech
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with history of left parietal glioblastoma s/p avastin last
___, CVA with baseline right-sided weakness presents with
confusion, unintelligible mumbling, and worsening R weakness for
the past 2 weeks. Per his son who is at the bedside (also HCP)
He
has not had diarrhea, constipation, dysuria, cough, fever, or
any
loss of consciousness however for the past two weeks he has been
uttering confused mumbling which is much worse than his baseline
though he does have confusion and word finding difficulty since
his cancer diagnosis. The patient lives with his daughter, who
manages his medications. His son here now does not know the home
medications at this time. Regarding his GBM, he completed
chemoradiation, and started cyclic temozolomide, but progressed
clinically and radiologically and started bevacizumab as above.
He has not complained of chest pain, dyspnea, or pain at all.
ED COURSE:
T 98.0 HR 74 BP 136/82 RR 16 97%RA. UA reassuring. Labs
reassuring (bun/cr ___ of note) glucose 93. LFTs reassuring.
WBC 14 with 56% pmns. Hct 44, plts 234. BNP 28. Pt was give n1L
NS. CXR no pneumonia. CT head without acute process, known left
temporal mass similar hypodensity in distribution compared to
MRI
from ___. Cspine CT showed no acute traumatic injury.
At the time of my interview the patient appears calm and
comfortable but mutters unintelligibly answers to questions. He
does follow some commands however and is clearly alert and
tracking with his eyes. Otherwise ROS unable to be obtained.
Past Medical History:
PAST ONCOLOGIC HISTORY:
TREATMENT HISTORY:
___ N/V started
___ Brain MRI showed left temporal mass
___ Biopsy by Dr. ___: glioblastoma
___ Partial resection by Dr. ___: glioblastoma
___ - ___ IMRT/TMZ 30x2 Gy by Dr. ___
___ Brain MRI shows progression
___ C1 TMZ
___ C2 TMZ
___ Admission with decline and failure to thrive
___ Brain MRI shows progression
___ C3 TMZ
___ C1 Bevacizumab
___ Brain MRI showed mixed response
___ C2 Bevacizumab
___ C4 TMZ
___ C3 Bevacizumab
___ Admission after a fall
___ Right zoster ophtalmicus
___ Brain MRI stable
___ C5 TMZ
___ C4 Bevacizumab
___ C6 TMZ
___ C5 Bevacizumab
___ C7 TMZ
___ Brain MRI showed progression
___ C6 Bevacizumab
___ C8 TMZ
___ C7 Bevacizumab
___ C9 TMZ
___ C8 Bevacizumab
___ C9 Bevacizumab
___ C10 TMZ
___ Brain MRI showed progression
___ C10 Bevacizumab
___ C11 Bevacizumab
___ C11 TMZ
___ C12 Bevacizumab
PAST MEDICAL HISTORY:
1. Left temporal glioblastoma
2. Dural AV fistula, bifrontal craniotomy with microsurgical
obliteration ___
3. Chronic headaches
4. Hepatitis B
5. Arthritis, right knee
6. Hypertension
7. Herpes zoster ophthalmicus, right
Social History:
___
Family History:
He has four healthy children. He has six healthy siblings. His
mother died at ___ in a car accident and his father died at ___
with a brain tumor.
Physical Exam:
Admission Physical
====================
VITAL SIGNS: 98.0 162/93 67 18 96%RA
General: NAD, calm, appears comfortable, very alert and awake
HEENT: MMM, no OP lesions, no cervical, supraclavicular, or
axillary adenopathy, no thyromegaly
CV: RR, NL S1S2 no S3S4 MRG
PULM: CTAB but shallow inspirations not clearly following deep
breathing commands
GI: BS+, soft, largely NTND, no masses or hepatosplenomegaly.
Mild tenderness to palpation in RLQ but no guarding/rebound
LIMBS: No edema, clubbing, tremors, or asterixis; no inguinal
adenopathy
SKIN: No rashes or skin breakdown
NEURO: Mutters unintelligibly (per son who speaks ___
when asked questions. DOes follow some commands and tracks
spontaneously with eyes, lifts his arms in the air when asked to
do so in ___ and motion is mimicked for him. Right side
clearly weaker, per son this is chronic. RLE and RUE with ___
strength and left extremities with ___ strength. PERRLA.
Discharge Physical
===================
98.3 PO124 / 77 L Lying 74 1897 RA
General: Comfortable, following basic commands
HEENT: Anicteric, eyes conjugate, MMM, no JVD
Cardiovascular: RRR no MRG, nl. S1 and S2
Pulmonary: Lung fields clear to auscultation throughout
Gastroinestinal: Soft, non-tender, non-distended, bowel sounds
present, no HSM
MSK: No edema
Skin: No rashes or ulcerations evident
Neurological: Awake, unable to assess orientation, 2+/5 strength
on right, 3+/5 distally, 2+/5 more proximally, 4+/5 strength on
left
Pertinent Results:
Admission Labs:
================
___ 07:00PM BLOOD WBC-14.1* RBC-6.34* Hgb-13.9 Hct-44.3
MCV-70* MCH-21.9* MCHC-31.4* RDW-18.2* RDWSD-40.5 Plt ___
___ 07:00PM BLOOD Neuts-56.6 ___ Monos-10.3 Eos-7.0
Baso-0.9 Im ___ AbsNeut-7.96* AbsLymp-3.48 AbsMono-1.45*
AbsEos-0.99* AbsBaso-0.12*
___ 07:00PM BLOOD ___ PTT-31.5 ___
___ 07:00PM BLOOD Glucose-93 UreaN-23* Creat-1.2 Na-137
K-3.9 Cl-98 HCO3-26 AnGap-17
___ 07:00PM BLOOD ALT-30 AST-25 AlkPhos-72 TotBili-0.4
___ 07:00PM BLOOD Albumin-4.4 Calcium-9.0 Phos-3.9 Mg-2.7*
Discharge Labs:
================
___ 05:00PM BLOOD WBC-11.6* RBC-6.51* Hgb-14.3 Hct-44.9
MCV-69* MCH-22.0* MCHC-31.8* RDW-17.6* RDWSD-39.4 Plt ___
___ 05:00PM BLOOD Glucose-111* UreaN-23* Creat-1.2 Na-140
K-3.7 Cl-104 HCO3-20* AnGap-20
___ 05:00PM BLOOD ALT-31 AST-25 AlkPhos-77 TotBili-0.4
___ 05:00PM BLOOD Calcium-9.4 Phos-4.8* Mg-2.2
Micro:
========
Urine culture ___: negative
Blood cultures ___: NGTD
Imaging:
==========
MRI Head w/ and w/o contrast ___:
1. Study is mildly degraded by motion.
2. Findings concerning for interval progression of ___
known left temporal GBM, as described.
3. Interval progression of left parietal occipital lobe
parenchymal signal intensity abnormalities, as described,
concerning for tumor progression.
4. Left posterior limb of the internal capsule acute infarction
versus tumor infiltration.
5. Interval progression of bilateral left greater than right
white matter signal abnormality, concerning for tumor
infiltration and/or post treatment changes.
CT head w/o contrast ___:
1. No acute intracranial abnormality.
2. Known left temporal mass with white matter hypodensity
similar in
distribution compared FLAIR signal abnormalities on MR from
___.
CT Cspine w/o contrast ___:
1. Mild anterolisthesis of the C2-C3 vertebral levels is
possibly degenerative in etiology, although difficult to
definitively conclude given the absence of prior studies.
2. Mild degenerative changes in the cervical spine with
mild-to-moderate
multilevel spinal canal and mild neural foraminal stenosis, as
described in
detail above.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Artificial Tears Preserv. Free ___ DROP BOTH EYES Q4H
2. Labetalol 400 mg PO TID
3. Pantoprazole 40 mg PO Q24H
4. Senna 17.2 mg PO DAILY
5. Timolol Maleate 0.5% 1 DROP BOTH EYES BID
6. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
7. Docusate Sodium 100 mg PO BID
8. Polyethylene Glycol 17 g PO DAILY
9. Simethicone 40-80 mg PO QID:PRN abdominal bloating
10. Erythromycin 0.5% Ophth Oint 0.5 in RIGHT EYE BID
11. Entecavir 0.5 mg PO DAILY
12. OxyCODONE (Immediate Release) 5 mg PO Q12H:PRN Pain -
Moderate
Discharge Medications:
1. Erythromycin 0.5% Ophth Oint 0.5 in RIGHT EYE BID
2. Ondansetron 8 mg PO DAILY Duration: 5 Days
Take prior to chemotherapy
3. temozolomide 400 mg oral DAILY Duration: 5 Days
4. Topiramate (Topamax) 50 mg PO Q12H
RX *topiramate 50 mg 1 tablet(s) by mouth every twelve (12)
hours Disp #*60 Tablet Refills:*0
5. Labetalol 200 mg PO TID
RX *labetalol 200 mg 1 tablet(s) by mouth three times a day Disp
#*90 Tablet Refills:*0
6. Artificial Tears Preserv. Free ___ DROP BOTH EYES Q4H
7. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
8. Docusate Sodium 100 mg PO BID
9. Entecavir 0.5 mg PO DAILY
10. OxyCODONE (Immediate Release) 5 mg PO Q12H:PRN Pain -
Moderate
11. Pantoprazole 40 mg PO Q24H
12. Polyethylene Glycol 17 g PO DAILY
13. Senna 17.2 mg PO DAILY
14. Simethicone 40-80 mg PO QID:PRN abdominal bloating
15. Timolol Maleate 0.5% 1 DROP BOTH EYES BID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Glioblastoma Multiforme with progress
Right sided Weakness
Dysarthria
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: History: ___ with weakness, intracranial mass// eval for
intracranial injury
TECHNIQUE: Contiguous axial images from skullbase to vertex were obtained
without intravenous contrast. Coronal and sagittal reformations and bone
algorithms reconstructions were also performed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 16.0 s, 17.4 cm; CTDIvol = 46.0 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: MR brain from ___.
FINDINGS:
The patient is status post left temporal craniotomy and frontal craniotomy
with expected postsurgical changes. Again seen is a partially resected Mass
with calcification in the left temporal fossa. Extensive edema involving the
right frontal lobe and left frontal and temporal lobes is similar in
distribution compared 2 MR from ___. There is ex vacuo dilation of
the left lateral ventricle. Bifrontal encephalomalacia is noted. No new
hypodensity suggest acute infarct or evidence of hemorrhage is identified.
Ventricles and sulci are enlarged, similar in caliber compared prior exam.
The paranasal sinuses, mastoid air cells, and middle ear cavities are clear.
The orbits are unremarkable.
IMPRESSION:
1. No acute intracranial abnormality.
2. Known left temporal mass with white matter hypodensity similar in
distribution compared FLAIR signal abnormalities on MR from ___.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ with weakness// eval for pneumonia
COMPARISON: Prior exam is dated ___.
FINDINGS:
AP upright and lateral views of the chest provided.
Volumes are low limiting assessment. There is hilar congestion with mild
interstitial pulmonary edema. No convincing evidence for pneumonia. No large
effusion pneumothorax. Cardiomediastinal silhouette is stable. Bony
structures are intact. No free air below the right hemidiaphragm.
IMPRESSION:
Hilar congestion with mild interstitial pulmonary edema. No convincing
evidence for pneumonia.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST
INDICATION: ___ with fall, R-sided weakness// evall for c-spine fx
TECHNIQUE: Non-contrast helical multidetector CT was performed. Soft tissue
and bone algorithm images were generated. Coronal and sagittal reformations
were then constructed.
DOSE: Total DLP (Body) = 858 mGy-cm.
COMPARISON: None.
FINDINGS:
There is mild anterolisthesis of the C2-C3, possibly degenerative in etiology,
although difficult to definitively conclude given the absence of prior
studies. No fractures are identified. There is mild-to-moderate multilevel
spinal canal narrowing due to osteophyte formation and posterior disc bulge,
notably at the C4-C5 and C5-C6 vertebral levels. Mild degenerative changes
are seen in the cervical spine, particularly at the C5-C6 level. Mild neural
foraminal stenosis noted at the C5-C6 level bilaterally. There is no
prevertebral soft tissue swelling. The thyroid gland appears normal. The lung
apices appear clear.
IMPRESSION:
1. Mild anterolisthesis of the C2-C3 vertebral levels is possibly degenerative
in etiology, although difficult to definitively conclude given the absence of
prior studies.
2. Mild degenerative changes in the cervical spine with mild-to-moderate
multilevel spinal canal and mild neural foraminal stenosis, as described in
detail above.
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST T___ MR HEAD
INDICATION: ___ year old man with glioblastoma status post surgical resection
in ___ and chemoradiation, now with worsening weakness and falls.
Evaluate for disease progression, edema or ischemic stroke.
TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After
administration of 8 mL of Gadavist intravenous contrast, axial imaging was
performed with gradient echo, FLAIR, diffusion, and T1 technique. Sagittal
MPRAGE imaging was performed and re-formatted in axial and coronal
orientations.
COMPARISON: ___ contrast brain MRI.
___ noncontrast head CT.
FINDINGS:
Study is mildly degraded by motion.
There are postsurgical changes from left temporal craniotomy. Again noted is a
irregular, heterogeneously enhancing left temporal mass which, along its
maximal ___, measures 8.0 x 4.7 cm (700:71), larger as compared to MRI
head ___, previously measuring 7.4 x 5.0 cm. Furthermore, in the
anterior aspect of this mass, there is a more homogeneously enhancing solid
component measuring 2.3 x 2.2 cm (700:71), new since ___. There
is also associated dural thickening and enhancement. There are associated
diffusion abnormalities in the posterior aspect of this mass (402:11)
Along the periventricular white matter in the left parietal and occipital
lobes there is subtle ill-defined rim enhancement measuring approximately 1.9
x 1.6 cm (700:93) with associated restricted diffusion (402:17), significantly
increased in size compared to ___. Centered in the left thalamus
and likely involving the posterior limb of the internal capsule, there is a
subtle irregular rim enhancing area measuring 1.7 x 1.4 cm (700:95) with
associated restricted diffusion (402:18) and mild surrounding vasogenic edema,
new since ___. These favors tumor spread versus less likely acute
infarction.
In the posterior limb of the left internal capsule, there is a focus of
enhancement measuring approximately 4 x 3 mm (700:89) with associated
restricted diffusion(402:16), new since ___, which could represent
acute infarction versus tumor spread.
There are small foci of susceptibility on gradient echo sequences in the area
of the dominant left temporal mass (6:7), some of which are new as compared to
___ and likely represent small areas of hemorrhage. Diffuse
vasogenic edema involving the left cerebral cortex and to a smaller extent the
right cerebral cortex is mildly increased since ___. Ex vacuo
change of left lateral ventricle is unchanged. The major intracranial vessels
signal is normal. However the M1 and M2 portions of the left middle cerebral
artery course through the dominant left temporal mass, minimally changed from
___.
There is mild mucosal thickening of the bilateral ethmoid air cells. The
remaining paranasal sinuses are patent. The orbit is normal.
IMPRESSION:
1. Study is mildly degraded by motion.
2. Findings concerning for interval progression of patient's known left
temporal GBM, as described.
3. Interval progression of left parietal occipital lobe parenchymal signal
intensity abnormalities, as described, concerning for tumor progression.
4. Left posterior limb of the internal capsule acute infarction versus tumor
infiltration.
5. Interval progression of bilateral left greater than right white matter
signal abnormality, concerning for tumor infiltration and/or post treatment
changes.
NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___
___ on the telephone on ___ at 3:19 pm, 10 minutes after discovery of
the findings.
Gender: M
Race: ASIAN - SOUTH EAST ASIAN
Arrive by WALK IN
Chief complaint: Abnormal CT, R Weakness
Diagnosed with Weakness
temperature: 98.0
heartrate: 74.0
resprate: 16.0
o2sat: 97.0
sbp: 136.0
dbp: 82.0
level of pain: 0
level of acuity: 2.0 | Mr. ___ is a ___ year old man with history of left temporal lobe
glioblastoma s/p avastin and temozolomide, last avastin ___,
post-op CVA with baseline right-sided
weakness, HTN and chronic Hep B presenting with worsening right
sided weakness and dysarthria with MRI head showing progression
of interval progression of left parietal signal intensities
concerning for tumor progression.
# Right sided weakness
# Dysarthria
# Subacute decline ___ glioblastoma with progression
Patient initially presented with worsening weakness and
dysarthria (mumbled speech) over the course of a few weeks.
Initial CT head without evidence of acute intracranial change
however MRI w/ and w/o contrast on HD2 showed progression of
glioblastoma. Additionally, patient was noted to no longer be
taking topamax which raised concern for possibility of seizures
contributing to picture. On discussion between Dr. ___
the ___ family on ___ ___, decision was made to trial one
more round of chemotherapy with increased dose of temozolomide
at home and consider transition to hospice if this is not
effective. Per the ___ family, the ___ energy and
strength mildly improved during hospitalization though no
interventions made during this admission.
# Low grade fever: Patient had low grade temp of 99.8 on ___
and stayed overnight to ensure no other signs or symptoms of
infection. Repeat labs stable and patient remained afebrile for
24 hours prior to discharge.
# Hepatitis B: continued entecavir. Please monitor closely as
outpatient given history of lactic acidosis with entecavir.
# Hypertension: Patient takes labetalol 400mg TID at home. This
was initially held and lowered to 200mg TID at discharge given
normotension. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Penicillins / Statins-Hmg-Coa Reductase Inhibitors
Attending: ___.
Chief Complaint:
Left ___ toe dry gangrene
Major Surgical or Invasive Procedure:
___: LLE angiogram, Stenting L SFA, angioplasty of BK pop
& AT origin
History of Present Illness:
___ with history of IDDM s/p renal transplant PVD with tissue
loss s/p R femoral-AT bypass graft ___ here with a non
healing left foot ulcer. The patient is non ambulatory and her
husband does most of her wound care as she is legally blind,
additionally she has neuropathy so she is dependent on him for
her wound care. She was recently admitted and treated with IV
antibiotics for her left toe ulcer with improvement. Plan was
for inpatient angiogram, but this was deferred due to patient
preference and she was discharged home on oral antibiotics with
plans for outpatient follow-up and scheduled angiogram. She
presents today with worsening of her left toe ulcer in the
setting of not taking her antibiotics as prescribed due to
associated nausea. Her daughter reports that she noted some
purulent discharge from the toe beginning yesterday so she
decided to present to the ED for evaluation. She denies any
fevers, chills, chest pain, or shortness of breath.
Past Medical History:
MHx:
T2DM, neuropathy, PVD
kidney transplant ___ ___
h/o PVD, ___ fem-AT right side c/b ?drop from OR table
causing disruption of bypass graft
SHx: ___
Family History:
unremarkable family history
Physical Exam:
Vitals: AVSS, see flowsheets
GEN: NAD, A&Ox3
CV: RRR
PULM: no respiratory distress
ABD: Obese, soft, non-tender, non-distended
EXT: UE edematous b/l
RLE: d/-/d/d, Right bypass scar well healed,
LLE: p/-/d/d, incision is c/d/I with sutures and
steri-strips in place
Pertinent Results:
===============
Pertinent labs
===============
___ 06:14AM BLOOD Glucose-89 UreaN-14 Creat-1.5* Na-138
K-4.8 Cl-101 HCO3-25 AnGap-12
___ 06:54AM BLOOD Glucose-69* UreaN-17 Creat-1.9* Na-125*
K-4.6 Cl-89* HCO3-23 AnGap-13
___ 04:56AM BLOOD TSH-4.4*
___ 04:56AM BLOOD T4-7.4 T3-51*
___ 04:16PM URINE Color-Yellow Appear-Hazy* Sp ___
___ 04:16PM URINE Blood-NEG Nitrite-NEG Protein-30*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-SM*
___ 04:16PM URINE RBC-2 WBC-1 Bacteri-FEW* Yeast-NONE Epi-1
___ 04:16PM URINE CastHy-28*
___ 04:16PM URINE Hours-RANDOM Na-20 Cl-28
___ 04:16PM URINE Osmolal-289
___ 06:56AM BLOOD WBC-9.1 RBC-3.12* Hgb-8.3* Hct-27.0*
MCV-87 MCH-26.6 MCHC-30.7* RDW-18.6* RDWSD-57.9* Plt ___
___ 05:48AM BLOOD WBC-10.1* RBC-3.08* Hgb-8.1* Hct-26.5*
MCV-86 MCH-26.3 MCHC-30.6* RDW-18.4* RDWSD-57.2* Plt ___
___ 12:56PM BLOOD WBC-8.0 RBC-3.14* Hgb-8.3* Hct-26.7*
MCV-85 MCH-26.4 MCHC-31.1* RDW-18.4* RDWSD-56.5* Plt ___
___ 05:19AM BLOOD WBC-8.2 RBC-3.12* Hgb-8.4* Hct-26.4*
MCV-85 MCH-26.9 MCHC-31.8* RDW-18.2* RDWSD-55.7* Plt ___
___ 06:14AM BLOOD WBC-7.9 RBC-3.08* Hgb-8.1* Hct-25.8*
MCV-84 MCH-26.3 MCHC-31.4* RDW-17.9* RDWSD-54.4* Plt ___
___ 04:56AM BLOOD WBC-8.1 RBC-3.25* Hgb-8.6* Hct-26.9*
MCV-83 MCH-26.5 MCHC-32.0 RDW-17.5* RDWSD-52.4* Plt ___
___ 12:15PM BLOOD Neuts-84.9* Lymphs-4.2* Monos-9.5
Eos-0.6* Baso-0.2 Im ___ AbsNeut-9.29* AbsLymp-0.46*
AbsMono-1.04* AbsEos-0.07 AbsBaso-0.02
___ 05:50PM BLOOD Neuts-79.0* Lymphs-7.6* Monos-10.5
Eos-1.7 Baso-0.4 Im ___ AbsNeut-7.91* AbsLymp-0.76*
AbsMono-1.05* AbsEos-0.17 AbsBaso-0.04
___ 06:56AM BLOOD ___ PTT-29.5 ___
___ 05:48AM BLOOD ___ PTT-27.7 ___
___ 12:56PM BLOOD ___ PTT-27.7 ___
___ 06:56AM BLOOD Glucose-127* UreaN-15 Creat-1.6* Na-139
K-4.7 Cl-100 HCO3-29 AnGap-10
___ 05:48AM BLOOD Glucose-41* UreaN-13 Creat-1.5* Na-141
K-4.7 Cl-101 HCO3-27 AnGap-13
___ 12:56PM BLOOD Glucose-124* UreaN-13 Creat-1.6* Na-137
K-4.4 Cl-99 HCO3-28 AnGap-10
___ 06:30AM BLOOD Glucose-118* UreaN-16 Creat-1.5* Na-134*
K-5.0 Cl-96 HCO3-26 AnGap-12
___ 03:25PM BLOOD Glucose-150* UreaN-17 Creat-1.6* Na-128*
K-4.7 Cl-92* HCO3-25 AnGap-11
===============
Studies
===============
Right upper extremity US (___): IMPRESSION: No evidence of
deep vein thrombosis in the right upper extremity. No residual
thrombus identified within the right internal jugular vein.
CXR (___): IMPRESSION: In comparison with the study of
___, the cardiomediastinal silhouette is stable. There
is increased indistinctness of engorged pulmonary markings,
consistent with worsening pulmonary vascular congestion. Left
pleural effusion is seen on the lateral view.
===============
Microbiology
===============
C. diff toxin PCR (___): NEGATIVE
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 5 mg PO DAILY
2. Aspirin 325 mg PO DAILY
3. Calcitriol 0.25 mcg PO DAILY
4. Carvedilol 25 mg PO BID
5. CloNIDine 0.3 mg PO BID
6. Furosemide 40 mg PO DAILY
7. Levothyroxine Sodium 50 mcg PO DAILY
8. Mycophenolate Mofetil 500 mg PO BID
9. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
10. Tacrolimus 1 mg PO Q12H
11. albuterol sulfate 90 mcg inhalation Q4H:PRN shortness of
breath/wheezing
12. Clindamycin 600 mg PO ONCE:PRN prior to dental procedures
13. Ciprofloxacin HCl 500 mg PO Q12H
14. MetroNIDAZOLE 500 mg PO Q8H
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Ciprofloxacin HCl 500 mg PO Q12H
3. Clopidogrel 75 mg PO DAILY
4. Docusate Sodium 100 mg PO BID:PRN Constipation
5. Ipratropium-Albuterol Neb 1 NEB NEB Q6H
6. MetroNIDAZOLE 500 mg PO Q8H
7. OxyCODONE (Immediate Release) 2.5-5 mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg ___ tablet(s) by mouth Q4H:PRN Disp #*5
Tablet Refills:*0
8. Pantoprazole 40 mg PO Q24H
9. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third
Line
10. Vitamin D 1000 UNIT PO DAILY
11. albuterol sulfate 90 mcg inhalation Q4H:PRN shortness of
breath/wheezing
12. amLODIPine 5 mg PO DAILY
13. Aspirin 325 mg PO DAILY
14. Calcitriol 0.25 mcg PO DAILY
15. Carvedilol 25 mg PO BID
16. Clindamycin 600 mg PO ONCE:PRN prior to dental procedures
17. CloNIDine 0.3 mg PO BID
18. Furosemide 40 mg PO DAILY
19. Glargine 14 Units Breakfast
Glargine 8 Units Bedtime
Insulin SC Sliding Scale using REG Insulin
20. Levothyroxine Sodium 50 mcg PO DAILY
21. Mycophenolate Mofetil 500 mg PO BID
22. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
23. Tacrolimus 1 mg PO Q12H
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Peripheral vascular disease, dry gangrene of left ___ toe
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: Chest AP and lateral
INDICATION: ___ with pitting edema// volume status
TECHNIQUE: Chest AP and lateral
COMPARISON: Chest radiograph dated ___.
FINDINGS:
Lungs are well aerated. Streaky bibasilar opacities likely represent
atelectasis. No focal consolidations are seen. Cardiomediastinal and hilar
silhouettes are unchanged. No pulmonary edema. No pneumothorax.
IMPRESSION:
No acute intrathoracic process.
Radiology Report
EXAMINATION: UNILAT LOWER EXT VEINS LEFT
INDICATION: ___ with necrotic left great toe, swelling/edema of calf// dvt
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the left lower extremity veins.
COMPARISON: Ultrasound dated ___.
FINDINGS:
There is normal compressibility, flow, and augmentation of the left common
femoral, femoral, and popliteal veins. The posterior tibial and peroneal
veins are not well visualized.
There is normal respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
Subcutaneous soft tissue edema is noted over the left calf.
IMPRESSION:
No evidence of deep venous thrombosis in the left lower extremity veins.
Subcutaneous soft tissue edema is noted over the left calf.
Radiology Report
INDICATION: ___ year old woman with pvd w/nausea// ileus?
TECHNIQUE: PORTABLE SUPINE RADIOGRAPH OF THE ABDOMEN.
COMPARISON: CT abdomen pelvis dated ___ and abdominal radiograph
dated ___.
FINDINGS:
There is a nonspecific bowel gas pattern with air-filled loops of bowel in the
left mid abdomen. Air is seen within the colon.
Assessment for free intraperitoneal air is limited on supine radiographs. If
there is clinical concern for pneumoperitoneum, advise upright or left lateral
decubitus radiograph, or cross-sectional imaging.
Degenerative changes are seen in the low lumbar spine and lumbosacral
junction. Vascular calcifications are noted.
There are no unexplained soft tissue calcifications or radiopaque foreign
bodies.
IMPRESSION:
Nonspecific bowel gas pattern with air-filled loops of bowel in the left mid
abdomen. If further evaluation is required, CT would have to be performed.
Radiology Report
INDICATION: ___ year old woman with ESRD s/p DDRT, PVD s/p R femoral-AT bypass
graft w/ chronic ulcer L great toe with cellulitis and ischemic changes.//
Please eval for effusion, PNA
TECHNIQUE: AP portable chest radiograph
COMPARISON: ___
FINDINGS:
There is no evidence of focal consolidation, pleural effusion or pneumothorax
identified. The size of the cardiac silhouette is mildly enlarged but
unchanged. Calcification of the aortic arch is again noted.
IMPRESSION:
No radiographic evidence of acute cardiopulmonary disease.
Radiology Report
EXAMINATION: DX CHEST PORTABLE PICC LINE PLACEMENT
INDICATION: ___ year old woman with new line // new right PICC 48 cm ___
___ Contact name: ___: ___ new right PICC 48 cm ___
___
IMPRESSION:
Go there to chest radiographs since ___ most recently ___.
Although mild to moderate cardiomegaly and pulmonary vascular congestion have
not progressed, there is more mild pulmonary edema in the left lung today than
there was on ___. Small left pleural effusion is also likely. No
right pleural effusion. No pneumothorax.
Right PIC line ends close to the superior cavoatrial junction.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ year old woman with stroke stat// Stroke stat
TECHNIQUE: Routine unenhanced head CT was performed and viewed in brain
window.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 10.0 s, 17.0 cm; CTDIvol = 48.8 mGy (Head) DLP =
829.0 mGy-cm.
Total DLP (Head) = 842 mGy-cm.
COMPARISON: None available.
FINDINGS:
There is no intra-axial or extra-axial hemorrhage, edema, shift of normally
midline structures, or evidence of acute major vascular territorial
infarction. Prominent ventricles and sulci compatible with age-related
involutional changes. Periventricular white matter hypoattenuation is
nonspecific but could represent chronic small vessel ischemic disease. A
hypodensity is noted in the left basal ganglia likely reflecting a chronic
lacunar infarct.
There is mucosal thickening in the bilateral ethmoid air cells. Remaining
paranasal sinuses are clear. Mastoid air cells and middle ear cavities are
well aerated. The bony calvarium is intact. There are severe atherosclerotic
calcifications of the bilateral carotid siphons.
IMPRESSION:
No acute intracranial abnormality. Please note that MRI is more sensitive for
the detection of acute infarction.
Radiology Report
EXAMINATION: CTA HEAD AND CTA NECK Q16 CT NECK
INDICATION: ___ year old woman with c/f stroke// c/f stroke
TECHNIQUE: Subsequently, helically acquired rapid axial imaging was performed
from the aortic arch through the brain during the infusion of Omnipaque
intravenous contrast material. Three-dimensional angiographic volume rendered,
curved reformatted and segmented images were generated on a dedicated
workstation. This report is based on interpretation of all of these images.
DOSE: Acquisition sequence:
1) Stationary Acquisition 0.5 s, 1.0 cm; CTDIvol = 3.7 mGy (Head) DLP = 3.7
mGy-cm.
2) Stationary Acquisition 2.5 s, 1.0 cm; CTDIvol = 18.7 mGy (Head) DLP =
18.7 mGy-cm.
3) Spiral Acquisition 11.2 s, 43.2 cm; CTDIvol = 38.8 mGy (Head) DLP =
1,626.0 mGy-cm.
Total DLP (Head) = 1,674 mGy-cm.
COMPARISON: None.
FINDINGS:
The study is partially degraded due to motion artifact.
CTA HEAD:
There is significantly limited evaluation of the intracranial vessels due to
motion artifact. The vessels of the circle of ___ and their principal
intracranial branches appear grossly normal without stenosis, occlusion, or
aneurysm formation. The dural venous sinuses are patent.
A partially calcified right posterior parietal extra-axial lesion (series 6,
image 419) is favored to represent a small calcified meningioma or a dural
plaque.
The
CTA NECK:
There are atherosclerotic calcifications at the origins of the great vessels.
Calcified atheromatous plaque at the origin of the right ICA results in up to
60% stenosis. The carotid and vertebral arteries and their major branches
appear otherwise normal with no evidence of stenosis or occlusion. There is no
evidence of left internal carotid stenosis by NASCET criteria.
OTHER:
The visualized portion of the lungs demonstrate interlobular septal
thickening, small bilateral pleural effusions and passive atelectasis. The
thyroid gland contains multiple subcentimeter hypoattenuating thyroid nodules
and a relatively prominent left thyroid lobe. There is no lymphadenopathy by
CT size criteria.
IMPRESSION:
1. Markedly limited study due to motion artifact.
2. Allowing for this, there is no gross vascular abnormality of the head and
neck.
3. Calcified atheromatous plaque resulting in up to 60% stenosis of the right
ICA. No evidence of left internal carotid stenosis by NASCET criteria.
4. Small partially calcified right posterior parietal extra-axial lesion is
favored to represent a partially calcified meningioma or a dural plaque.
5. Evidence of mild pulmonary edema with associated small pleural effusions
and passive atelectasis.
6. Multiple subcentimeter thyroid nodules.
RECOMMENDATION(S): Thyroid nodule. No follow up recommended.
Absent suspicious imaging features, unless there is additional clinical
concern, ___ College of Radiology guidelines do not recommend further
evaluation for incidental thyroid nodules less than 1.0 cm in patients under
age ___ or less than 1.5 cm in patients age ___ or ___.
Suspicious findings include: Abnormal lymph nodes (those displaying
enlargement, calcification, cystic components and/or increased enhancement) or
invasion of local tissues by the thyroid nodule.
___, et al, "Managing Incidental Thyroid Nodules Detected on Imaging: White
Paper of the ACR Incidental Findings Committee". J ___ ___
12:143-150.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with ESRD s/p DDRT, PVD w/ gangrene, concern
for pulmonary edema/effusion// Please eval for pulm edema/effusion, other
interval change Please eval for pulm edema/effusion, other interval change
IMPRESSION:
Comparison to ___. Slightly increasing small left pleural
effusion, with subsequent left basal parenchymal opacity with air
bronchograms. Mild pulmonary edema persists. Moderate cardiomegaly. No
pneumothorax.
Radiology Report
EXAMINATION: UNILAT UP EXT VEINS US RIGHT
INDICATION: ___ year old woman with worsening RUE swelling// Please eval for
DVT
TECHNIQUE: Grey scale and Doppler evaluation was performed on the right upper
extremity veins.
COMPARISON: None.
FINDINGS:
There is normal flow with respiratory variation in the bilateral subclavian
vein.
The right internal jugular vein is noncompressible and contains echogenic
internal debris consistent with deep vein thrombosis. Venous flow is
demonstrated on color and spectral Doppler imaging, this is consistent with
nonocclusive DVT.
The right axillary veins are patent, show normal color flow and
compressibility. The right brachial, basilic, and cephalic veins are patent,
compressible and show normal color flow and augmentation.
IMPRESSION:
Nonocclusive deep vein thrombosis of the right internal jugular vein.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, on the telephone on ___ at 3:24 pm, 60 minutes after
discovery of the findings.
Radiology Report
INDICATION: ___ PMH ESRD s/p DDRT, PVD s/p R femoral-AT bypass graft w/
chronic ulcer L great toe with cellulitis and ischemic changes.// abi/pvr s/p
intervention, interval change
TECHNIQUE: Non-invasive evaluation of the arterial system in the lower
extremities was performed with Doppler signal recording, pulse volume
recordings and segmental limb pressure measurements.
COMPARISON: ___ noninvasive arterial exam.
FINDINGS:
On the right side, monophasic doppler waveforms are seen in the right femoral,
popliteal, and dorsalis pedis arteries. The right posterior tibial and
dorsalis pedis arteries are noncompressible. A posterior tibial waveform was
unable to be obtained.
The right ABI was unable to be calculated. Right TBI of 0.27.
On the left side, monophasic doppler waveforms are seen in the left femoral,
popliteal, and dorsalis pedis arteries. A posterior tibial waveform was
unable to be obtained.
The left ABI was 0.73. Previously, the ABI was 0.15 on ___.
IMPRESSION:
1. Improvement in left ABI, which is now 0.73 (previously 0.15 on ___. However, there are persistent monophasic waveforms seen within the
left popliteal, and dorsalis pedis arteries, compatible with moderate arterial
insufficiency.
2. Moderate to severe right lower extremity arterial insufficiency, with
noncompressible posterior tibial and dorsalis pedis arteries. Right ABI unable
to be calculated. Right TBI of 0.27.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ PMH ESRD s/p DDRT, PVD s/p R femoral-AT bypass graft w/
chronic ulcer L great toe with cellulitis and ischemic changes now endorsing
SOB. Evaluate for interval change.
TECHNIQUE: Frontal view of the chest.
COMPARISON: Chest x-ray ___ through ___.
FINDINGS:
Stable, mild to moderate cardiac enlargement. Stable, small left pleural
effusion. Stable, left lower lobe opacity, which could be atelectasis or
pneumonia. Unchanged mild pulmonary edema. No pneumothorax.
A right PICC terminates in the lower SVC.
IMPRESSION:
Unchanged mild pulmonary edema.
Unchanged small left pleural effusion.
Unchanged left lower lobe opacity, which could be atelectasis or pneumonia.
Stable, mild to moderate cardiomegaly.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old woman with asthma and PVD s/p renal transplant with
wheezing and dry crackles on exam// evaluate for pulmonary edema
IMPRESSION:
In comparison with the study of ___, the cardiomediastinal silhouette
is stable. There is increased indistinctness of engorged pulmonary markings,
consistent with worsening pulmonary vascular congestion. Left pleural
effusion is seen on the lateral view.
Radiology Report
EXAMINATION: UNILAT UP EXT VEINS US
INDICATION: ___ year old woman with nonocclusive deep vein thrombosis of the
right internal jugular vein// please evaluate for progression of DVT
TECHNIQUE: Grey scale and Doppler evaluation was performed on the right upper
extremity veins.
COMPARISON: Right arm ultrasound ___
FINDINGS:
There is normal flow with respiratory variation in the subclavian veins
bilaterally.
The right internal jugular, axillary and brachial veins are patent, show
normal color flow and compressibility. The right basilic and cephalic veins
are patent.
IMPRESSION:
No evidence of deep vein thrombosis in the right upper extremity. No residual
thrombus identified within the right internal jugular vein.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Wound eval
Diagnosed with Cellulitis of left toe
temperature: 97.5
heartrate: 62.0
resprate: 18.0
o2sat: 100.0
sbp: 183.0
dbp: 55.0
level of pain: 0
level of acuity: 3.0 | ___ was admitted to ___ on ___ for work-up and
treatment of dry gangrene of her left ___ toe. On ___ she
underwent stenting of the left SFA, angioplasty of BK pop & AT
origin (under general anesthesia). On ___ she underwent a
left transmetatarsal amputation under sedation and a leg lower
extremity nerve block. She tolerated this procedure well and did
not experience any post-anesthetic side effects.
Neuro and Mental Status
It was noted her mental status did not return to baseline
following the procedure on ___ with inability to follow
commands. A code stroke was called and a non-contrast head CT
was obtained and did not show an acute hemorrhage. Over the next
few hours, her mental status improved without intervention.
Ultimately, the change in mental status was felt to be related
to anesthetic effect. Throughout her hospitalization her mental
status continued to improved and returned to baseline. On
___ she underwent a left transmetatarsal amputation under
sedation and a leg lower extremity nerve block. She tolerated
this procedure well and did not experience any post-anesthetic
side effects.
Acute kidney injury
--------------------
Patient is status-post deceased donor kidney transplant in ___,
maintained on tacrolimus and mycohenolate. Due to an increase in
her creatinine after receiving two contrast loads and having an
episode of hypotension, she was transferred to the Medicine
service. Her baseline Cr is between 1.3-1.4 and increased to
1.9. Her urine was spun and showed hyaline casts, consistent
with contrast-induced nepropathy. Her home diuretics were
temporarily held. She was continued on her home tacrolimus 0.5
mg PO BID and MMF 500 mg PO BID. Her Cr decreased to 1.5 and her
home Lasix 40 mg PO daily was restarted in the setting of volume
overload on exam. She was started on a low phos diet.
Diarrhea
--------
Patient had loose stools after starting antibiotics. C. diff was
negative. CMV viral load was not checked as patient did not have
any other systemic manifestations or lab findings concerning for
CMV. Diarrhea self-resolved.
Wheezing
---------
Patient had one episode of wheezing and dyspnea. She was given
DuoNebs. She reportedly has a history of asthma, which is
exacerbated by seasonal allergies and intermittently uses
albuterol at home. She was restarted on her home diuretics for
bibasilar crackles heard on exam as well, which may have been
contributing.
Pericardial effusion
--------------------
Moderate pericardial effusion noted on TTE, which had increased
in size from last TTE in ___. Cardiology was consulted, who
recommended checking thyroid function tests, which were
abnormal, but should be repeated outside of the setting of acute
illness. She should follow up with Cardiology as outpatient and
have a repeat TTE in one month.
Chronic ischemic left great toe
Patient underwent angioplasty and stenting on ___ with
Vascular Surgery. Dorsalis pedis pulses were checked daily with
Doppler and were present. She was treated with oral
ciprofloxacin and metronidazole and had betadine dressing
changes per Podiatry recommendations.
Hyponatremia
------------
Patient with hyponatremia in the setting of holding diuretics.
She was placed a 1.2L free water restriction and this resolved
after restarting home Lasix.
Upper extremity edema
Patient noted to have RUE edema. Ultrasound showed non-occlusive
thrombus in right IJ. US later repeated and no thrombus was
seen.
By ___ the patient was deemed ready for discharge to a
rehabilitation facility. She was tolerating a diet, her pain was
well controlled and her mental status was at baseline. She
expressed understanding of her discharge instructions and plans
for follow-up care.
TRANSITIONAL ISSUES
===================
[] TTE in one month
[] Cardiology follow-up for pericardial effusion
[] Repeat thyroid function studies while not acutely ill
[] Tacro level goal: ___
[] Will need to continue antibiotics (cipro/flagyl) until
instructed to stop by her providers as they monitor her clinical
course to ensure her cellulitis and infection has resolved.
***Please wrap left ___ with gauze and kerlix very loosely
(almost falling off) as any increased pressure could lead to
skin breakdown*** |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
morphine
Attending: ___.
Chief Complaint:
left arm weakness s/p MVC
History of Present Illness:
This is a ___ year-old male presenting with left arm weakness and
pain s/p MVC several hours ago. The patient reports that he was
sideswiped by another car on the highway, then subsequently
rear-ended another car at high speed. Pt reports that he was
unrestrained. Per EMS, the patient was initially pulseless on
scene with the police but had ROSC and was alert and oriented at
the time of their arrival shortly afterward.
The patient was subsequently seen at ___ ED
where he had CT of the head (negative), torso (no acute
finding),
and c-spine, which demonstrated severe spinal stenosis in the
upper cervical spine, relating to large posterior vertebral
osteophyte and ligament ossification. On initial presentation to
the OSH ED, the patient reported that he was unable to move his
arms or legs directly after the accident, but reported full
recovery of strength and sensation in his bilateral lower
extremities prior to the time of transfer to ___.
On presentation, the patient states that he now feels that he
has
full sensation in bilateral lower extremities, and the right
upper extremity. He reports shooting pains from his left
shoulder
to his left hand, and reports weakness in the left hand and arm.
He denies bowel or bladder incontinence.
Past Medical History:
HTN
Social History:
___
Family History:
NC
Physical Exam:
AFVSS
General: resting comfortably in bed with C-collar
Mental Status:
Spine: (tenderness)
No bruising or swelling appreciated. skin clean, dry and intact.
mild ttp over c-spine @ C4-7, no step-off or deformity
Vascular (R/L)
Radial 2+/2+
DP 2+/2+
Sensory UE (R/L)
C5 (Ax) nL/nL
C6 (MC) nL/nL
C7 (Mid finger) nL/nL
C8 (MACN) nL/nL
T1 (MBCN) nL/nL
T2-L2 Trunk nL/nL
Sensory ___ (R/L)
L2(Groin) nL/nL
L3(Leg) nL/nL
L4(Knee) nL/nL
L5(Grt Toe) nL/nL
S1(Sm toe) nL/nL
S2(Post Thigh) nL/nL
Motor UE (R/L)
Deltoid(C5)Ax nL/ ___
Biceps(C6)MC nL/ ___
WE(C6)R nL/ ___
Triceps(C7)R nL/nL
WF(C7)M nL/ ___
FF(C8)AIN nL/ ___
Fing Abd(T1)U nL/ ___
Motor ___ (R/L)
Add(L2) nL/nL
Quad(L3) nL/nL
Ant Tib(L4/DP) nL/nL
___ nL/nL
Peroneal(S1/SP) nL/nL
___ nL/nL
Reflexes (R/L)
Biceps(C4-5) 1+/1+
BR(C5-6) 1+/1+
Triceps (C6-7) 1+/1+
Patellar (L3-4) 1+/1+
Achilles(L5-S1) 1+/1+
Straight Leg Raise Test: normal
___: normal
Babinski: appropriate flexor plantar response
Clonus: none
Perianal sensation: intact, good rectal tone
Estimated Level of Cooperation: Excellent
Estimated Reliability of Exam: Excellent
Pertinent Results:
___ 05:00PM GLUCOSE-134* UREA N-16 CREAT-0.9 SODIUM-141
POTASSIUM-4.5 CHLORIDE-106 TOTAL CO2-22 ANION GAP-18
___ 05:00PM ETHANOL-75*
___ 04:20PM WBC-10.5 RBC-4.81 HGB-15.1 HCT-46.3 MCV-96
MCH-31.4 MCHC-32.6 RDW-13.7
Radiology Report
HISTORY: Injury.
TECHNIQUE: Single supine AP view of the chest.
COMPARISON: None.
FINDINGS:
Underlying trauma board and other external artifact partially obscure the
view. Given this, no focal consolidation, pleural effusion, or evidence of
pneumothorax is seen. The cardiac and mediastinal silhouettes are
unremarkable. No displaced fracture is seen.
IMPRESSION:
No acute intrathoracic process seen.
Radiology Report
HISTORY: Spinal pain after motor vehicle accident, left arm weakness,
evaluate for cord contusion.
TECHNIQUE: Multiplanar multisequence MRI of the cervical, thoracic, and
lumbar spine was obtained without IV contrast as per department protocol.
COMPARISON: No prior.
FINDINGS:
Cervical spine: There is mild increased STIR signal in the prevertebral soft
tissues from C2-C4 level and to a lesser extent from C4-C7 levels suggesting
ligamentous injury. There is high T2 signal within the C5-C6 disk suspicious
for disc injury. There is high T2, high STIR, and isointense T1 signal in the
anterior epidural space along the posterior margin of the C2 vertebral body
extending inferiorly to C4 suspicious for epidural hematoma. There are
superimposed broad-based disc bulges at C2-C3 and C3-C4 levels. There is
abnormal signal within the cord from C2-C3 and C3-C4 suggesting
compression/contusion due to a combination of diffuse disc bulges and epidural
hematoma. At C5-C6, there is a left paracentral disc protrusion deforming the
cord without abnormal signal within the cord.
At C6-C7, there is a broad-based disc protrusion resulting in moderate
bilateral neural foraminal narrowing. There is deformity of the anterior
thecal sac without evidence of deformity of the cord.
The paraspinal soft tissues are unremarkable. The vertebral body heights are
within normal limits.
Thoracic spine: There is no evidence of abnormal STIR signal. The vertebral
body heights are unremarkable. The disc spaces are normal. The bone marrow
signal is unremarkable.
At T2-T3, there is an small disc bulge without evidence of spinal canal or
neural foraminal narrowing. Otherwise, the spinal canal is preserved
throughout the cervical spine. There is no evidence of abnormal cord signal.
At T11-T12, there is diffuse ligamentum flavum thickening indenting the thecal
sac posteriorly without deforming the cord.
Lumbar spine: The alignment is normal. The bone marrow signal is
unremarkable with the exception of a hemangioma within the L2 vertebral body.
The vertebral body heights are normal. The conus medullaris terminates at L1
and has normal signal and configuration.
At L4-L5 and L5-S1, diffuse disc bulges are noted indenting the thecal sac.
There is a left far lateral disc protrusion disc protrusion at at L4-L5.
The paraspinal soft tissues are unremarkable.
IMPRESSION:
1. Cord contusion/compression at C2-C3 and C3-C4 due to a combination of
diffuse disc bulges and epidural hematoma as described.
2. Abnormal STIR signal in the prevertebral soft tissues as described
suggesting ligamentous injury.
3. Abnormal T2 hyperintensity in the C5-C6 disc in keeping with disc injury.
4. These findings were discussed with Dr. ___ 12:37 pm, on ___ via
phone, and they were aware of all the findings.
Gender: M
Race: OTHER
Arrive by AMBULANCE
Chief complaint: MVC
Diagnosed with CENTRAL CORD SYND/C5-C7, MV COLLISION NOS-DRIVER
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: nan | Patient was admitted to the ___ Spine Surgery Service and
observed for improvement of neuro status. He was diagnosed with
a cord contusion and central cord syndrome. He was kept in a
collar. His MRI demonstrated spinal stenosis at C2-4 and a disc
injury at C5-6. It was determined that he would be treated
non-operatively for a week and then undergo an anterior and
posterior decompression and fusion. Foley was removed on HD2.
Physical therapy was consulted for mobilization OOB to ambulate.
Hospital course was otherwise unremarkable. On the day of
discharge the patient was afebrile with stable vital signs,
comfortable on oral pain control and tolerating a regular diet. |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Compazine
Attending: ___
Chief Complaint:
Persistent fevers
Major Surgical or Invasive Procedure:
None
History of Present Illness:
PCP: Dr. ___
___ female with hematomachrosis treated with regular
phlebotomy based on blood leves who presents with fever of
unknown origin. The patient was in her usual state of good
health except for an episode hives the month prior to her sx
starting and then she had 3 episodes of high fevers with a
MAXIMUM TEMPERATURE of 105 over last 3 weeks.
With regards to the episodes of hives, she developed pruritis on
the back of her neck. She thought it was a mosquito bite. She
then went out to see her neighbor who told her that she had a
rash on her skin. She then took prednisone for 5 days after
receiving a shot of steroids in urgent care. The next day it
resolved. She was admitted to an outside hospital twice. Testing
has been negative for infectious source both times. However, in
between the 2 hospitalization she was found to have a pneumonia
and completed course of antibiotics and 4 days of prednisone.
Reviewing her d/c summary from her first admission in ___,
she was found to have a small pleural effusion along with
atelectasis and thus she was treated with levaquin. Imaging also
revealed thickening of the gallbladder with possible fluid
accumulation in the gallbladder. This raised the possibility of
cholecysititis but the patient did not have sx clinically. A
HIDA scan was negative. CT scan also demonstrated diverticulae
without diverticulitis. During the admission her bilirubin did
increase but then went back down to 1.2. Her LFTS remained
elevated at AST/ALT: 93/208 at discharge decreasing from
482/316. Rheumatologic w/u included lupus panel in which a PTT
was slightly elevated, and a cardiolipin IgG was slightly
elevated at 19 which was indeterminate.
She is up to date with mammograms having had one in the last
year and she had a colonoscopy within the past ___ years that
was WNL per patient.
Of note she also received 6 days of prednisone for the pinched
nerve in her neck to see if it could control the
stinging/pruritis on her arms. The treatment that best helped
that in the end was physicial therapy.
She recently traveled here from ___ on ___ to
attend a college ___ but denies any other travel. She
reports that the fever started again today. She was seen at ___
___ and found to be febrile to 101.4. A chest x-ray
(negative)and blood tests were performed. Her lactate was
elevated to 3.8. Potassium low at 3.4. LFTS WNL including direct
bilirubin. WBC = 4.0 with 93% PMNS. UA negative. HCT = 38.7 with
MCV = 106.9.
The patient was then transferred to ___. Patient denies any
symptoms currently. She denies any chest pain, shortness of
breath, rhinorrhea, congestion cough. Denies any headache. She
has chronic neck pain and developed back pain when making the
bed this am which has occurred before. She denies any
weakness, numbness, tingling. She denies any urinary
incontinence or retention. She denies any bowel incontinence or
retention. She has no history of IV drug use, malignancy,
anticoagulation. She denies any sick contacts. She denies ever
traveling to ___ or the ___. No sick contact
She has had veneers put on two bottom teeth 3 months ago. No
spinal injections. No recent surgeries.
+ 6 lb weight loss
+ nausea -> emesis today and it occurred before when her fever
was elevated. No nausea prior to that. Mild hot flashes since
menopause at night but no night sweats. When she has the fever
she has flushing on her cheeks. + Rigors when her fevers occurs
such that she cannot hold anything in her hands.
She felt better after her first admission but after the second
admission she never felt better because of fatigue, indigestion.
Last endoscopy ___ years ago which demonstrated polyps in her
stomach
___ LAB REVIEW
LFTS:
ALT 316/AST482
with a flat bilirubin
Her K trnded down to 3.0
In the ED :
triage VS:
3| 99.2| 99| 138/72| 13 |97% Nasal Cannula\
___ 01:05POAcetaminophen 1000 ___
___ 01:06POOxycoDONE (Immediate Release) 5
___
___ 02:22IVF1000 mL D5NS + 20 mEq Potassium
___ MStarted 150 mL/
No consults called and no imaging performed.
======================================
REVIEW OF SYSTEMS:
CONSTITUTIONAL: As per HPI
HEENT: [X] All normal
RESPIRATORY: [X] All normal
CARDIAC: [X] All normal
GI: As per HPI- no diarrhea
GU: [X] All normal- including no dysuria
SKIN: [+] Per hPI
MUSCULOSKELETAL: [+] Per HPI
NEURO: [X] All normal
ENDOCRINE: [X] All normal
HEME/LYMPH: [+] chronic easy bruising without bleeding
PSYCH: [X] All normal
All other systems negative except as noted above
Past Medical History:
HTN
H/o pinched nerve -> itch
Hemachromatosis
Diverticulsos
Glaucoma
Social History:
___
Family History:
Her father died ___ Body Dementia at ___. He also had a
h/o CAD s/p CABG. Her mother had a heart condition and died of
old age at ___. Her sister is a breast cancer survivor s/p b/l
masectomy
Physical Exam:
ADMISSION
VS: T98.6 P 73 BP 133/78 RR18 SaO2 97% on RA
CONS: NAD, comfortable appearing
HEENT: ncat anicteric MMM
CV: s1s2 rr, soft SEM at ___
BREAST EXAM:
Very lumpy breast tissue, difficult to discern a focal mass
RESP: b/l ae no w/c/r
GI: +bs, soft, + RUQ tenderness without rebound or guarding
back:+ tenderness at R parasinal space at L5
GU:no CVaT b/l
MSK:no c/c/e 2+pulses
SKIN: + ? b/l facial flushing
NEURO: face symmetric speech fluent
PSYCH: calm, cooperative
LAD: no cervical, supraclavicular, axillary, or femoral
lymphadenopathy.
DISCHARGE
VS: T98.6 118/60 ___
GEN: Well appearing female in no distress
HEENT: No scleral icterus
HEART: RRR, normal S1 S2, no murmurs
LUNGS: Clear, no wheezes or rales
ABD: Soft, NT ND, normal BS
EXT: No edema
NEURO: Alert, oriented
Pertinent Results:
ADMISSION LABS
___ 12:42AM ___ PTT-24.3* ___
___ 12:14AM COMMENTS-GREEN
___ 12:14AM LACTATE-2.0
___ 12:05AM GLUCOSE-112* UREA N-8 CREAT-0.7 SODIUM-143
POTASSIUM-3.2* CHLORIDE-104 TOTAL CO2-22 ANION GAP-20
___ 12:05AM estGFR-Using this
___ 12:05AM ALT(SGPT)-33 AST(SGOT)-78* ALK PHOS-44 TOT
BILI-1.4
___ 12:05AM LIPASE-21
___ 12:05AM ALBUMIN-4.1
___ 12:05AM WBC-8.7 RBC-3.53* HGB-12.8 HCT-37.0 MCV-105*
MCH-36.3* MCHC-34.6 RDW-13.5 RDWSD-50.9*
___ 12:05AM NEUTS-95.0* LYMPHS-2.0* MONOS-1.2* EOS-1.2
BASOS-0.3 IM ___ AbsNeut-8.23* AbsLymp-0.17* AbsMono-0.10*
AbsEos-0.10 AbsBaso-0.03
___ 12:05AM PLT COUNT-180
___ 12:05AM PARST SMR-NEGATIVE
==========================================
CT CHEST:
Supraclavicular and axillary lymph nodes are not enlarged.
Excluding the
breasts which require mammography for evaluation, elsewhere in
the chest wall there are no soft tissue abnormalities concerning
for malignancy or infection.
There are no thyroid lesions warranting further imaging
evaluation.
Atherosclerotic calcification is not apparent head neck vessels
or appreciable in the coronary arteries. Aorta and pulmonary
arteries and cardiac chambers are normal size. There is no
pleural or pericardial abnormality.
Prevascular mediastinal lymph nodes are noteworthy for number,
but not size. Largest mediastinal nodes are 9 mm, right lower
paratracheal station, 12 mm, subcarinal. Hilar nodes are not
enlarged. Esophagus is unremarkable.
Aside from mild to moderate bibasilar atelectasis, right greater
than left,
lungs are clear. Tracheobronchial tree is normal to
subsegmental levels.
There are no bone lesions in the chest cage suspicious for
malignancy.
IMPRESSION:
No evidence of intrathoracic infection. 2 top-normal
mediastinal nodes in
numerous smaller ones are not not necessarily pathologic.
___ imaging is not indicated.
RECOMMENDATION(S): ___ imaging is not indicated.
CT ABD/PELVIS:
ABDOMEN:
HEPATOBILIARY: The liver appears borderline hypodense compared
to the spleen. However, the background liver demonstrates
homogenous attenuation throughout. There is no evidence of focal
lesions. There is no evidence of intrahepatic or extrahepatic
biliary dilatation. The gallbladder is within normal limits.
PANCREAS: The pancreas has normal attenuation throughout,
without evidence of focal lesions or pancreatic ductal
dilatation. There is no peripancreatic stranding.
SPLEEN: The spleen shows normal size and attenuation throughout,
without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size
and shape.
URINARY: The kidneys are of normal and symmetric size with
normal nephrogram. There is no evidence of focal renal lesions
or hydronephrosis. There is no perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel
loops demonstrate normal caliber, wall thickness, and
enhancement throughout. Diverticulosis of the descending and
sigmoid colon is noted, without evidence of wall thickening and
fat stranding. The appendix is normal.
PELVIS: The urinary bladder and distal ureters are unremarkable.
There is no free fluid in the pelvis.
REPRODUCTIVE ORGANS: The uterus is in mid position, and is
normal in size.
There are no concerning adnexal masses.
LYMPH NODES: There is no retroperitoneal or mesenteric
lymphadenopathy. There is no pelvic or inguinal
lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Mild
atherosclerotic disease is noted.
BONES: There is no evidence of worrisome osseous lesions or
acute fracture. Mild degenerative changes of the lumbar spine is
seen.
SOFT TISSUES: The abdominal and pelvic wall is within normal
limits.
IMPRESSION:
1. No acute abdominopelvic process relating to reported history
of
high-temperature fevers.
2. Borderline hepatic steatosis.
3. Extensive sigmoid and descending colonic diverticulosis
without
diverticulitis.
4. Please refer to the dedicated chest CT for intrathoracic
findings.
___ LENIs
No evidence of deep venous thrombosis in the right or left lower
extremity
veins.
DISCHARGE LABS
___ 06:35AM BLOOD WBC-3.7* RBC-3.70* Hgb-13.3 Hct-38.8
MCV-105* MCH-35.9* MCHC-34.3 RDW-13.0 RDWSD-49.9* Plt ___
___ 06:35AM BLOOD Neuts-43.5 ___ Monos-13.2*
Eos-3.2 Baso-1.6* Im ___ AbsNeut-1.61# AbsLymp-1.41
AbsMono-0.49 AbsEos-0.12 AbsBaso-0.06
___ 06:35AM BLOOD Glucose-100 UreaN-11 Creat-0.6 Na-138
K-3.7 Cl-102 HCO3-24 AnGap-16
___ 06:35AM BLOOD ALT-43* AST-32 AlkPhos-45 TotBili-0.6
___ 06:35AM BLOOD Lipase-20
___ 06:35AM BLOOD Calcium-9.7 Phos-5.3* Mg-1.8
___ 06:35AM BLOOD Folate-9.4
___ 07:44AM BLOOD VitB12-738 Ferritn-294*
___ 12:05AM BLOOD TSH-2.5
___ 07:30AM BLOOD HBsAg-Negative HBsAb-Negative IgM
HBc-Negative IgM HAV-Negative
___ 07:44AM BLOOD ___
___ 12:05AM BLOOD CRP-12.3*
___ 07:40PM BLOOD HIV Ab-Negative
___ 12:14AM BLOOD Lactate-2.0
CMV Viral Load (Final ___:
CMV DNA not detected.
Performed by Cobas Ampliprep / Cobas Taqman CMV Test.
Linear range of quantification: 137 IU/mL - 9,100,000
IU/mL.
Limit of detection 91 IU/mL.
This test has been verified for use in the ___ patient
population.
LYME SEROLOGY (Final ___:
NO ANTIBODY TO B. BURG___ DETECTED BY EIA.
Reference Range: No antibody detected.
Negative results do not rule out B. burg___ infection.
Patients
in early stages of infection or on antibiotic therapy may
not produce
detectable levels of antibody. Patients with clinical
history and/or
symptoms suggestive of lyme disease should be retested in
___ weeks.
Blood, urine cultures NGTD
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Losartan Potassium 50 mg PO DAILY
2. Famotidine 20 mg PO BID
3. LamoTRIgine 50 mg PO DAILY
4. ALPRAZolam 0.25 mg PO DAILY:PRN anxiety
5. Tizanidine 4 mg PO QHS:PRN neck spasm
6. Lumigan (bimatoprost) 0.01 % ophthalmic QHS
7. Azopt (brinzolamide) 1 % ophthalmic BID
Discharge Medications:
1. ALPRAZolam 0.25 mg PO DAILY:PRN anxiety
2. Famotidine 20 mg PO BID
3. LamoTRIgine 50 mg PO DAILY
4. Losartan Potassium 50 mg PO DAILY
5. Tizanidine 4 mg PO QHS:PRN neck spasm
6. Azopt (brinzolamide) 1 % ophthalmic BID
7. Lumigan (bimatoprost) 0.01 % ophthalmic QHS
Discharge Disposition:
Home
Discharge Diagnosis:
Fever of unknown origin
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT of abdomen pelvis with contrast.
INDICATION: ___ year old woman with FUO to 105, hematomacrosis, who presents
with fever and RUQ pain along with elevated LFTS. // Please evaluate for
cause of fever.
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technique.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 0.5 s, 0.4 cm; CTDIvol = 5.7 mGy (Body) DLP = 2.3
mGy-cm.
2) Stationary Acquisition 26.9 s, 0.2 cm; CTDIvol = 449.9 mGy (Body) DLP =
90.0 mGy-cm.
3) Spiral Acquisition 7.1 s, 67.2 cm; CTDIvol = 6.4 mGy (Body) DLP = 433.3
mGy-cm.
Total DLP (Body) = 526 mGy-cm.
COMPARISON: None.
FINDINGS:
LOWER CHEST: Please refer to separate report of CT chest performed on the same
day for description of the thoracic findings.
ABDOMEN:
HEPATOBILIARY: The liver appears borderline hypodense compared to the spleen.
However, the background liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesions. There is no evidence of intrahepatic
or extrahepatic biliary dilatation. The gallbladder is within normal limits.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There is no evidence of focal renal lesions or hydronephrosis. There is no
perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement throughout. Diverticulosis of
the descending and sigmoid colon is noted, without evidence of wall thickening
and fat stranding. The appendix is normal.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The uterus is in mid position, and is normal in size.
There are no concerning adnexal masses.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease
is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
Mild degenerative changes of the lumbar spine is seen.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. No acute abdominopelvic process relating to reported history of
high-temperature fevers.
2. Borderline hepatic steatosis.
3. Extensive sigmoid and descending colonic diverticulosis without
diverticulitis.
4. Please refer to the dedicated chest CT for intrathoracic findings.
Radiology Report
EXAMINATION: CT CHEST W/CONTRAST
INDICATION: Fever right upper quadrant pain an hemochromatosis. Assess for
possible pneumonia.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 0.5 s, 0.4 cm; CTDIvol = 5.7 mGy (Body) DLP = 2.3
mGy-cm.
2) Stationary Acquisition 26.9 s, 0.2 cm; CTDIvol = 449.9 mGy (Body) DLP =
90.0 mGy-cm.
3) Spiral Acquisition 7.1 s, 67.2 cm; CTDIvol = 6.4 mGy (Body) DLP = 433.3
mGy-cm.
Total DLP (Body) = 526 mGy-cm.
** Note: This radiation dose report was copied from CLIP ___ (CT ABD AND
PELVIS WITH CONTRAST)
FINDINGS:
There are no prior chest CT scans for comparison.
Supraclavicular and axillary lymph nodes are not enlarged. Excluding the
breasts which require mammography for evaluation, elsewhere in the chest wall
there are no soft tissue abnormalities concerning for malignancy or infection.
Findings below the diaphragm will be reported separately.
There are no thyroid lesions warranting further imaging evaluation.
Atherosclerotic calcification is not apparent head neck vessels or appreciable
in the coronary arteries. Aorta and pulmonary arteries and cardiac chambers
are normal size. There is no pleural or pericardial abnormality.
Prevascular mediastinal lymph nodes are noteworthy for number, but not size.
Largest mediastinal nodes are 9 mm, right lower paratracheal station, 12 mm,
subcarinal. Hilar nodes are not enlarged. Esophagus is unremarkable.
Aside from mild to moderate bibasilar atelectasis, right greater than left,
lungs are clear. Tracheobronchial tree is normal to subsegmental levels.
There are no bone lesions in the chest cage suspicious for malignancy.
IMPRESSION:
No evidence of intrathoracic infection. 2 top-normal mediastinal nodes in
numerous smaller ones are not not necessarily pathologic. Follow-up imaging
is not indicated.
RECOMMENDATION(S): Follow-up imaging is not indicated.
Radiology Report
EXAMINATION: BILAT LOWER EXT VEINS
INDICATION: ___ woman with fever of unknown origin visiting from
___ evaluate for deep venous thrombosis.
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the bilateral lower extremity veins.
COMPARISON: No prior relevant imaging is available on PACS at the time of
this dictation.
FINDINGS:
There is normal compressibility, flow, and augmentation of the bilateral
common femoral, femoral, and popliteal veins. Normal color flow and
compressibility are demonstrated in the posterior tibial and peroneal veins.
There is normal respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
No evidence of deep venous thrombosis in the right or left lower extremity
veins.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Fever, Transfer
Diagnosed with Fever, unspecified
temperature: 99.2
heartrate: 99.0
resprate: 13.0
o2sat: 97.0
sbp: 138.0
dbp: 72.0
level of pain: 3
level of acuity: 3.0 | ___ year old female with hematochromatosis, HTN who presents with
recurrent intermittent fevers x 1 month.
# FEVER OF UNKNOWN ORIGIN: The patient has had intermittent
fevers to 105 over the last 4 weeks with now ___ hospitalization
without etiology discovered. She has had a work up and been
treated for pneumonia. No other source has been identified and
the patient was afebrile while in the hospital. She has no
localizing symptoms. She reports mild back pain for 1 day.
Otherwise she had a rash ___ weeks prior to onset of initial
fever. No other symptoms and no travel outside state of ___
until now. Up to date with cancer screening per patient.
Ferritin mildly elevated (rule out adult Still's disease, also
no true joint involvement). ___ negative. CMV VL negative.
Parasite smear negative, Lyme negative, and no growth on
cultures. CT Torso without any findings. Ultrasound negative for
DVTs in the legs. She was afebrile in the hospital and her
cultures were negative at 48 hours. She had mild elevation in
her LFTs that improved without intervention. UA was negative.
She was seen by Rheumatology who did not think there was an
autoimmune or rheumatologic explanation for her symptoms. She
was stable for discharge with outpatient PCP ___. She had
mild leukopenia which will need to be repeated as an outpatient.
# PARSPINAL BACK SPASM/TENDERNESS: New in setting of making bed.
She had mild tenderness in her paraspinal muscles after feeling
like she pulled a muscle. Patient was fully ambulatory without
neuro findings and paraspinal tenderness.
# HTN: continued losartan
# DYSPEPSIA: continued H2 blocker
# NECK SPASM: continued lamtrigine/tizandine prn
### TRANSITIONAL ISSUES ###
-No cause for FUO was identified
-Repeat CBC as outpatient for mild leukopenia
-Recommend outpatient Heme and ID followup |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Back pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with multiple co-morbidities, including a history of back
pain who presents with weakness, worsening back pain. Patient
was recently admitted for hyperkalemia, UTI, CHF exacerbation,
and LLE cellulitis. Diuresed while inpatient, and sent home on
cefpodoxime for complicated UTI and cellulitis. Patient has
been using a wheelchair for some time and is s/p amputation of R
leg. Patient states that today, he was weaker than usual. He is
usually able to stand with assistance but today was unable to do
so. He states that he has had problems for some time with
strength, but that today he feels weaker. He has also had
cellulitis in the L foot. Denies cp/sob/ab pain.
In the ED, initial vs were: 10 97.2 56 167/59 20 100%
Exam notable for ttp over midline of the L spine, poor strength
in the RLE; RLE amputation with prosthesis.
Labs notable for creat 3.3 (recent baseline 2.7). CT pelvis and
lumbar spine revealed 3mm non-obstructing R kidney stone,
bladder wall thickening, multilevel degenerative joint disease
without acute fracture or dislocation.
Dr. ___ was called, and recommended holding off on
antibiotics, reculturing in 24 hours and consider restarting
antibiotics at this time.
He was given IVF, home dose of clonidine for hypertension, and
admitted to medicine.
On the floor the patient was confortable and had the following
complaints:
-___ Lower back pain
-___ Left hip pain
-___ toe pain
Past Medical History:
PAST MEDICAL HISTORY:
- CKD
- CAD
- Ischemic cardiomyopathy (EF 40-45%)
- Cervical and Lumbar Spinal Stenosis - s/p surgery
- CVA (silent, unknown chronology)
- Hypertension.
- Hypercholesterolemia.
- Diabetes mellitus
- Gout.
- h/o atrial fibrillation
- L2-S1 decompression c/b MRSA wound infection for which pt is
on chronic prophylatic rifampin given all the hardware.
- s/p RBKA for diabetic wound infection
- Normocytic anemia (Hct ~30 since ___ since ___
- DVT dx ___
Past Surgical History:
1. C3-C4 cervical fusion, ___
2. L3-L4 laminectomies in ___
3. Right CEA
4. Right leg vein bypass in ___.
5. Left hip replacement in ___
6. Right below-the-knee amputation, ___.
7. Posterior fusion L2-S1
Social History:
___
Family History:
No known history of heart disease.
Physical Exam:
ON ADMISSION:
==============
Vitals: 97.2 | 90/46 | 53 | 18 | 100%/RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, moderate conjunctival pallor, dry oral
mucosa, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Expansion is asymmetrical, diminished on the R. No breath
sounds in R base, no egophony. Otherwise clear to auscultation
bilaterally, no wheezes, rales, rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: RBKN. Warm, adequately perfused, 1+ pedial pulse, no
clubbing, cyanosis. BLE 2+ pitting edema. Erythema and
tenderness in ___ toe.
Skin: eythema w/o induration or tenderness at lower ___ of L
leg
Neuro: AOx3. No gross sensory or motor deficits.
MSK: TTP in lower back spinal processes as well as over L
trochanter. Active and passive ROMs preserved
ON DISCHARGE::
==============
Vitals 98, BP 124/40(124-147/36-51), HR 70, RR 18, O2 100%RA
Gen: Pleasant, elderly main laying in bed s/p right leg
amputation in NAD
Extremities: s/p R foot and L great toe amputation. Tip of ___
toe with dried blood and erythema, no warmth or surrouding
erythema, but R pretibial area is mildly erythematous.
Heart: RRR, no m/r/g
Lungs: CTAB
Abd: Soft, NT/ND, +BS
Neuro: AOx3, pleasant, conversing fluently about recent and
remote events
Pertinent Results:
ADMISSION LABS:
================
___ 12:40PM BLOOD WBC-4.6 RBC-2.87* Hgb-8.9* Hct-27.9*
MCV-97 MCH-31.1 MCHC-32.0 RDW-14.3 Plt ___
___ 12:40PM BLOOD ___ PTT-28.9 ___
___ 12:40PM BLOOD Glucose-105* UreaN-90* Creat-3.3* Na-139
K-4.9 Cl-103 HCO3-24 AnGap-17
___ 07:10AM BLOOD Calcium-8.2* Phos-5.6* Mg-2.4
PERTINENT LABS:
==============
___ 03:29AM URINE RBC->182* WBC->182* Bacteri-MANY
Yeast-NONE Epi-0
___ 03:29AM URINE Blood-MOD Nitrite-NEG Protein-300
Glucose-NEG Ketone-15 Bilirub-SM Urobiln-0.2 pH-6.0 Leuks-LG
___ 10:00PM URINE RBC-5* WBC->182* Bacteri-FEW Yeast-NONE
Epi-0
___ 10:00PM URINE Blood-SM Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-LG
___ 12:30PM URINE RBC-7* WBC->182* Bacteri-FEW Yeast-OCC
Epi-0
___ 12:30PM URINE Blood-SM Nitrite-NEG Protein-100
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG
___ 11:13AM URINE Eos-POSITIVE
___ 02:49PM URINE Hours-RANDOM UreaN-554 Creat-92 Na-45
K-30 Cl-22
___ 11:13AM URINE Hours-RANDOM UreaN-385 Creat-41 Na-81
K-32 Cl-73
DISCHARGE LABS:
=================
___ 08:20AM BLOOD WBC-5.1 RBC-2.50* Hgb-7.8* Hct-25.1*
MCV-100* MCH-31.2 MCHC-31.1 RDW-15.0 Plt ___
___ 08:20AM BLOOD Glucose-142* UreaN-70* Creat-3.4* Na-139
K-4.3 Cl-107 HCO3-22 AnGap-14
___ 08:20AM BLOOD Calcium-8.1* Phos-4.6* Mg-2.3
RELEVANT STUDIES:
================
CT L-SPINE W/C ___:
1. No evidence of acute fracture, though the exam is
significantly limited by severe osteopenia, metallic artifact
and degenerative changes.
2. Mild loss of height in T12 and L1, grossly unchanged from
___.
3. Status post L2 through S1 fusion with laminectomies of L3,
L4, and L5, and no definite evidence of hardware complication.
4. Severe multilevel degenerative changes with posterior
osteophytes and disc bulges extending posteriorly into the canal
with at least moderate spinal canal narrowing at multiple
levels.
5. 3-mm non-obstructing right renal stone.
6. Severe atherosclerotic disease.
CT PELVIS/HIP W/C ___:
1. No evidence of fracture.
2. Status post left total hip arthroplasty without evidence of
hardware
complication.
3. Moderate degenerative changes in the right hip, bilateral
sacroiliac
joints, and pubic symphysis.
4. Mild bladder wall thickening maybe due to chronic
obstruction from BPH, although correlation with UA is
recommended to exclude cystitis.
5. Diverticulosis without evidence of diverticulitis.
CXR ___: No acute cardiopulmonary process. Moderate
cardiomegaly.
ANIS ___: Findings as stated above which indicate
significant left SFA and tibial disease, overall similar to the
prior study of ___. Of note is a flat-line amplitude at
the left metatarsal level.
RENAL U/S ___:
1. No hydronephrosis, stones or solid renal mass.
2. Prostatic hypertrophy likely causes bladder outlet
obstruction, accounting for difficulty voiding.
MICROBIOLOGY:
=============
URINE CX ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN
AND/OR GENITAL CONTAMINATION
URINE CX ___:
<10,000 organisms/ml
URINE CX ___:
YEAST. >100,000 ORGANISMS/ML.
BLOOD CX ___ X 2:
NO GROWTH
Radiology Report
HISTORY: ___ female with acute on chronic injury. Evaluation for
hydronephrosis.
TECHNIQUE: Grayscale and color Doppler ultrasound images were obtained of the
bilateral kidneys and bladder.
COMPARISON: Comparison is made to ultrasound of the kidneys from ___.
FINDINGS: The right kidney measures 9.4 cm and the left kidney measures 9.7
cm. There is no evidence of hydronephrosis. No cyst, stone or solid mass is
identified in either kidney. The bladder is trabeculated and median lobe
prostate hyperplasia indents upon the bladder base. Layering debris is
present in the bladder.
IMPRESSION:
1. No hydronephrosis, stones or solid renal mass.
2. Prostatic hypertrophy likely causes bladder outlet obstruction, accounting
for difficulty voiding.
Radiology Report
INDICATION: Weakness. Evaluate for pneumonia.
COMPARISON: ___ chest radiograph.
FINDINGS: PA and lateral views of the chest. There is no focal
consolidation, pleural effusion, vascular congestion or pneumothorax. The
aorta is tortuous. There is moderate cardiomegaly. Otherwise, the
mediastinal and hilar contours are normal. There is mild elevation of the
right hemidiaphragm, unchanged.
IMPRESSION: No acute cardiopulmonary process. Moderate cardiomegaly.
Radiology Report
INDICATION: Back pain and weakness in the left leg. Evaluate for fracture.
COMPARISONS: Lumbosacral spine radiographs from ___. CT
abdomen and pelvis from ___.
TECHNIQUE: Contiguous helical MDCT images were obtained through the lumbar
spine without the administration of IV contrast. Sagittal, coronal, and bone
reformatted images were obtained and reviewed.
DLP TOTAL: 884.63 mGy-cm.
CTDI VOLUME: 30.94 mGy.
FINDINGS: The patient is status post L2 through S1 spinal posterior fusion
with laminectomies of L4 through L5. The hardware appears intact without
evidence of pedicle screw fracture. The rods are intact without evidence of a
fracture or malalignment. The post-surgical changes with graft material from
the posterior aspect of the pedicle screws are not significantly changed from
the prior exam.
There are severe multilevel degenerative changes with fusion of the left
aspect of the L2 and L3 vertebral bodies and near-complete fusion of the right
lateral aspect of the L4 and L5 vertebral bodies and the central aspect of the
L5 and S1 vertebral bodies. This is similar to the prior exam. There is mild
dextroscoliosis of the lumbar ___ at L2. There is straightening of
the normal lumbar lordosis. Alignment is otherwise stable without significant
anterolisthesis or retrolisthesis.
The exam is limited by significant osteopenia, though no definite acute
fracture is identified. There is mild loss of height in the anterior portion
of the vertebral body of T12, unchanged from the prior exam. There is mild
loss of height in L1, also unchanged.
At T11-T12, there is loss of disc space height, small Schmorl's nodes, and
vacuum phenomenon. There is likely a small disc bulge without significant
central canal narrowing.
At T12-L1, there is loss of disc height with small Schmorl's nodes. No
significant disc bulge is identified.
At L1-L2, there is severe loss of disc space height with significant vacuum
phenomenon, endplate sclerosis, and osteophyte formation. A partially
calcified osteophyte extends posteriorly into the central canal (400b, 30).
This is likely causing moderate central canal narrowing. Evaluation is
somewhat limited by surrounding metallic artifact.
At L2-L3, there is severe loss of disc space height, endplate sclerosis.
Evaluation at this level is significantly limited by surrounding metallic
artifact, although there is an eccentric disc bulge on the right (2, 27),
likely causing moderate central canal narrowing.
At L3-L4, disc space height is preserved essentially on the right due to an
interbody spacer. It is narrowed on the left. Interbody spacer has metallic
artifact, posteriorly, and evaluation for significant disc disease is limited.
At L4-L5, disc space height is also maintained due to interbody spacer. Again
due to the metallic artifact, it is difficult to evaluate for disc disease.
At L5-S1, there is severe disc space narrowing, endplate sclerosis, and
osteophyte formation. There is a small posterior osteophyte (400b, 38),
causing mild-to-moderate canal narrowing.
Evaluation of the thecal sac throughout this exam was limited due to technique
and artifact.
No free fluid is identified in the pelvis. The psoas muscles are grossly
symmetric without evidence of hematoma or fluid collection. No fluid
collection is identified in the paraspinal muscles or post-surgical bed.
There is a 3-mm non-obstructing right renal stone in the upper pole of the
kidney (3, 3). Smaller calcifications around the renal hilum are likely
atherosclerotic calcifications in the renal arteries. There are no left renal
stones. No mass is identified in the imaged portions of the kidneys. There is
no hydronephrosis. Imaged portions of the abdominal aorta are normal in
caliber without evidence of an aneurysm. There is severe atherosclerotic
disease, including at the takeoff of the celiac and SMA arteries.
IMPRESSION:
1. No evidence of acute fracture, though the exam is significantly limited by
severe osteopenia, metallic artifact and degenerative changes.
2. Mild loss of height in T12 and L1, grossly unchanged from ___.
3. Status post L2 through S1 fusion with laminectomies of L3, L4, and L5, and
no definite evidence of hardware complication.
4. Severe multilevel degenerative changes with posterior osteophytes and disc
bulges extending posteriorly into the canal with at least moderate spinal
canal narrowing at multiple levels.
5. 3-mm non-obstructing right renal stone.
6. Severe atherosclerotic disease.
Radiology Report
INDICATION: Back pain and weakness in the left leg. Evaluate for fracture.
COMPARISONS: CT of the lumbar spine obtained concurrently with this CT. CT
of the abdomen and pelvis from ___.
TECHNIQUE: Contiguous axial MDCT images were obtained through the pelvis
without the administration of IV or oral contrast. Sagittal and coronal
reformatted images were obtained and reviewed.
TOTAL DLP: 1425.02 mGy-cm.
FINDINGS: For details of the lumbar spine, please see the lumbar spine CT.
Note, the patient is status post a L2 through S1 fusion with postoperative
changes.
Post-surgical changes are noted in the sacrum. There is no evidence of a
sacral fracture. There are moderate degenerative changes of the bilateral
sacroiliac joints with sclerosis and small subchondral cysts.
The patient is status post a left bipolar total hip arthroplasty. The
hardware appears intact without evidence of loosening or dislocation.
Post-surgical changes are similar to the prior exam in ___. There is no
evidence of fracture of the left femur around the prosthesis. There is no
evidence of a pelvic fracture or right femur fracture. Moderate degenerative
changes are noted in the right hip and at the pubic symphysis.
Extensive atherosclerotic calcifications are noted in the bilateral common
iliac arteries, and in internal and external iliac arteries. There is
diverticulosis without evidence of diverticulitis. The imaged portions of the
small bowel are normal. There is no pelvic or inguinal lymphadenopathy.
There is no free fluid in the pelvis.
The prostate is mildly enlarged measuring 5.2 cm (2, 77). The bladder is
moderately distended. Apparent wall thickening may be chronic, though
recommend correlation with UA to exclude active cystitis.
The pelvic musculature demonstrates fatty infiltration and some asymmetry,
likely due to the left hip prosthesis. There is no evidence of intramuscular
hematoma. Calcifications in the left buttocks are likely injection
granulomas. There is moderate anasarca without a discrete fluid collection in
the soft tissues.
IMPRESSION:
1. No evidence of fracture.
2. Status post left total hip arthroplasty without evidence of hardware
complication.
3. Moderate degenerative changes in the right hip, bilateral sacroiliac
joints, and pubic symphysis.
4. Mild bladder wall thickening maybe due to chronic obstruction from BPH,
although correlation with UA is recommended to exclude cystitis.
5. Diverticulosis without evidence of diverticulitis.
Radiology Report
ARTERIAL STUDY DATED THE ___
HISTORY: Peripheral vascular disease and right BKA.
ABI on the left is 0.66 based on the DP artery. Doppler tracings demonstrate
monophasic waveforms actually from the superficial femoral vein, distally.
Volume recordings are in accord with the Doppler tracings.
IMPRESSION: Findings as stated above which indicate significant left SFA and
tibial disease, overall similar to the prior study of ___. Of note is a
flat-line amplitude at the left metatarsal level.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Back pain
Diagnosed with ACUTE KIDNEY FAILURE, UNSPECIFIED, URIN TRACT INFECTION NOS, LUMBAGO, DIABETES UNCOMPL ADULT, HYPERTENSION NOS, HYPERCHOLESTEROLEMIA
temperature: 97.2
heartrate: 56.0
resprate: 20.0
o2sat: 100.0
sbp: 167.0
dbp: 59.0
level of pain: 10
level of acuity: 2.0 | ___ year old man with significant past medical history including
CKD, HTN, DM, and right BKA, who presents after a fall, he's
found to have worsening renal function.
#s/p Fall: Fell in the tub. Fracture work-up negative. Contusion
of lower back and left him. Pain well controlled with standing
acetaminophen.
# Acute on chronic kidney injury: Came in with a creatinine of
3.3 up from 2.8 on last discharge. Patient has labile creatinine
clearance and oscillates between 2.5 and 3.5 due to his heavy
diuretic regimen. During his hospitalization his diuretics were
ultimately held for concern of pre-renal azotemia. He continued
to have worsening renal function. A foley was placed because of
urinary obstrution from BPH and he was noted to have pyuria with
negative bacterial urine cultures. AIN is also a possible
contributing factor to his renal dysfunction. Biopsy was
considered but would probably not be within his goals of care.
He will follow up with renal outpatient.
# Hyperkalemia: Resolved once diuretics were stopped and was
probably secondary to decreased renal perfusion.
# EF preserved HF: Rarely presents with lung congestion, often
presents with JVD and lower extremity edema. In this occasion he
was never overloaded.
#Arterial Toe Ulcer: Poorly healing shallow ulcer in the left
___ toe with surrounding erythema. Vascular found worsening
perfusion of the toe in ANIs this time but not candidate for
revascularization. Started ciprofloxacin/metronidazole for
presumptive overinfection along with bacitracin dry dressings.
Cipro was changed to cefpodoxime for concern that it may have
contributed to AIN. |